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Surgical Endoscopy

, Volume 33, Supplement 1, pp 414–483 | Cite as

2019 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Baltimore, Maryland, USA, 3–6 April 2019: Video Loop Videos

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V149

Spigelian Hernia: An uncommon cause of a common compliant

Matthew E Mobily, MD, MPH, Amlish B Gondal, MD, Eric Hines, BA, Iman Ghaderi, MD, MSc, MHPE; University of Arizona

In this video, we present a case of right Spigelian hernia in a 85 year old female with one year history of intermittent sharp right lower quadrant abdominal pain. She did not have any history of abdominal surgeries. On physical examination, there was right lower quadrant tenderness. There was no palpable mass or fascial defect. Her imaging was indeterminate. She was scheduled for robotic assisted transabdominal repair of right Spigelian hernia with mesh. There was not intraoperative complications and she was discharged home from recovery room.

V150

Laparoscopic resection of Liver Hemangioma: One of its kind!

Narendra Nikam, MS, FMAS, FIAGES, FBMS, FCLS, Abhijit Shah, MS, Ali Z Anwar, MS, Kushagra Rahul, MS; Sir JJ Group of Hospitals

Hemangiomas are the most common liver lesions. They are blood filled cavities lined by endothelial cells, usually supplied by the hepatic artery. The documented frequency is found to be 7% at autopsy. It is more common in adults between 30–50 years of age and is predominantly found in females, with a ratio of 5:1. Only 33 cases have been reported in the current literature.

They are usually asymptomatic. Surgical intervention is indicated in ruptured cases, intra-tumoral bleeding and coagulopathy.

The various surgical modalities for treatment include segmental resection, lobectomy or enucleation of tumour, which can be done by laparoscopy or by open surgery, with open surgery being the more commonly used modality of the two.

Here we present a case of a 45 year old female who presented with pain in abdomen in the right side. There was no significant past history or history of trauma.

Contrast enhanced CT of the abdomen and pelvis reports were significant for a highly dense fluid in the left lobe of liver.

Based on these findings, a ruptured hepatic hemangioma was suspected and patient was planned for surgery. Laparoscopic left lobe peripheral segmentectomy was done. Intra-operatively, findings have been described.

Post operatively, the patient was stable and recovered well.

It is with this experience in mind, we urge a change in Louisville statement and propose the beginning of a new criteria on which this once dreaded complication can be successfully tackled via Minimal access surgery.

V151

Giant Rectal ESD With Tissue Retraction: A Unique Approach

Sam K Sharma, James E East, Adam A Bailey; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, U.K.

Introduction: Hypothesis: The use of a novel endoscopic tissue retraction device was 1) feasible and 2) facilitated effective and efficient dissection of giant colonic polyps.

Giant colonic polyps (> 4 cm diameter) are often treated by surgical resection.

Endoscopic treatment options include piecemeal EMR or ESD but resection of large polyps, is more time-consuming and requires more resources compared with polypectomy of smaller lesions.

To overcome these challenges we have previously described a tissue retraction method to improve visualisation and increase dissection efficiency and effectiveness.

Here we report the first case series of 3 patients giant polyps removed via ESD using this technique.

Methods and procedures:
  • 3 patients – (2 female and 1 male)

  • Average age – 59.3 years

  • Procedure:

  • Patient was prepared and given conscious sedation according to trust guidelines.

  • We began in left lateral position and moved as needed

  • ESD with retraction procedure:

  • Circumferential incision using ESD knife

  • Mucosal edge clipped to foreballoon

  • Retraction varied according to dissection

  • Specimen captured in roth net and removed from patient

  • Mucosal defect inspected and clips applied as necessary

  • Equipment:

  • Olympus gastroscope (GIF) or colonoscope (PCF)

  • ESD cap

  • Fuji flushknife

  • Lumendi Dilumen

  • Haemostatic clips

  • Saline or sigmavisc submucosal injection

  • Olympus needle injector

  • ERBE electrosurgical generator

Results:
  • En-bloc resection completed in all cases.

  • Average Procedure Time (minutes) = 127.4

  • Average Specimen diameter size (cm) = 6.8

  • Average Rate of dissection (cm2/h) = 17.2

  • No complications

  • Histology was not available at the time of abstract submission.

Conclusion: The use of a novel endoscopic tissue retraction device was feasible and effective in the dissection of giant colonic polyps.

This was mediated via 1) improved tissue tension and 2) perforating blood vessel visibility facilitating efficient dissection and appropriate coagulation mediated therapy respectively.

Further expansion to this case series is on-going.

V152

Laparoscopic Repair of Perforated Type V Gastric Ulcer in a Patient with Recurrent Paraesophageal Hernia

Georgios Orthopoulos, MD, PhD, Parth Sharma, MD, Mazen Al-Mansour, MD; Baystate Medical Center/University of Massachusetts Medical School

This is a case of a 76 year old female with multiple medical comorbidities, abuse of Non-Steroidal Anti-Inflammatory Drugs due to chronic knee pain and remote history of laparoscopic paraesophageal hernia repair who presented with peritonitic signs and pneumoperitoneum. Exploratory laparoscopy revealed recurrence of the paraesophageal hernia and upon further exploration a perforated gastric ulcer near the diaphragmatic hiatus was identified. It was repaired with omental patch and intraoperative esophagogastroduodenoscopy was negative for leak. Patient tolerated the procedure well and was discharged home on postoperative day 5 after having a normal upper gastrointestinal series study and tolerating diet.

V153

What is the Limit for Safe Laparoscopic Approach in Complicated Diverticulitis?

Aurelio Francisco Aranzana Gomez, Jara Hernandez Gutierrez, Beatriz Muñoz Jimenez, Juan S Malo Corral; CH Toledo

Introduction: The diverticular disease of the colon is a chronic entity with a variety of abdominal symptoms that can present with recurrent episodes of acute diverticulitis (AD). The prevalence of diverticulosis is not influenced by gender and increases with age, which, according to the increase in life expectancy, explains the accumulation of cases in Western countries. The classic diagnostic and therapeutic algorithm of the disease is based on the modified Hinchey classification. The use of laparoscopy with washing and drainage in cases with peritonitis is nowadays more and more widespread.

The aim of the video is to demonstrate the safety and efficacy of the laparoscopic approach for the definitive treatment in cases with complicated diverticular disease.

Methods and Procedures: Clinical case: A 46-year-old man with history of Diverticulitis 10 years ago with complete resolution and normal control colonoscopy. He presents in the last two months 3 episodes of acute Diverticulitis. Physical examination reveals an inflammatory plastron in the hypogastric region without defense, CT-thickening of a 10 cm. segment of the sigma, with a 3 cm not drainable collection in the mesosigmoid. The complementary explorations and iconography of interest are exposed. Given the evolution, an elective surgical management is proposed.

Results: Preoperative bilateral ureteral catheterization, laparoscopic approach is performed. The video shows a rectosigmoid resection including the diverticular plastron, with negative intraoperative biopsy, a mechanical colorectal anastomosis was performed. Correct postoperative course and discharge on the 6th. PO day. Definitive result of the specimen: perforated Diverticulitis, absence of malignancy.

Conclusion(s): The laparoscopic approach is a valid and effective alternative in cases of complex and severe diverticular disease.

V154

Unexpected Finding of Gallbladder Torsion Resulting in Ischemia: A Rare Diagnosis

Jordan Wilkerson, MD, Cory Banaschak, DO, Amelie Lueders, MD, Viney Mathavan, MD; St. Vincent Hospital

This video abstract submission demonstrates an unexpected intra-operative finding of gallbladder torsion resulting in ischemia which was identified at the time of laparoscopic cholecystectomy. The patient presented is a 91 year-old male who presented with concern for acute cholecystitis based on symptoms and pre-operative imaging prompting surgical intervention. During laparoscopy, the patient’s gallbladder was noted to have minimal hepatic attachments resulting in an 180 degree organoaxial torsion with resulting vascular compromise. This relatively rare diagnosis, predominately seen in the elderly, represents a potential etiology of biliary symptoms that is amenable to surgery and best treated with early intervention.

V155

Thoracoscopic pericardial patch closure of iatrogenic tracheal injury during esophagectomy

Srikanth Gadiyaram, Dr, Gaurav Singh, Dr, Yashas H Ramegowda; Sahasra Hospitals, Centre of Excellence for Gastroenterology, Bangalore, India

Introduction: Iatrogenic tracheo-bronchial injury is an uncommon complication following esophagectomy with a reported incidence of 0.6–10% 1–3. Repair of a tracheal injury encountered in a patient during thoracoscopic esophagectomy in prone position is reported.

Methods: Fifty six year old lady a case of squamous cell carcinoma of the mid thoracic esophagus underwent thoraco-laparoscopic esophagectomy in prone position following completion of neo-adjuvant chemo-radiotherapy. Per-operatively, secondary to the neo-adjuvant therapy dense adhesions were noted in the region of mid thoracic esophagus adjoining the trachea-bronchial complex. An iatrogenic rent measuring about 1 × 0.75 cm resulted in the trachea at the region of carina during mediastinal lymphadenectomy. The tracheal injury was repaired primarily using a pericardial flap and further reinforced with the aid of an intercostal muscle interposition and fibrin glue. A chest tube was left in place.

Results: The total operative time was 385 min. Post-operatively she was electively ventilated for 24 hours. Chest tube did not show any air leak and was removed on post-operative day 3 after confirming lung expansion. She was discharged on post-operative day 7.

Conclusion: Iatrogenic tracheo-bronchial injury is a rare but dreaded complication of esophagectomy. These injuries can be efficiently and safely repaired using the thoracoscopic route. Both pericardial flap and intercostal muscle reinforcements can be used to further buttress the repair. Careful and limited use of energy sources during both dissection of the thoracic esophagus and mediastinal lymphadenectomy can safeguard against the occurrence of such injuries.

V156

Control of a Bleeding Dieulafoy Ulcer at the Gastroesophageal Junction with a Full Thickness Over the Scope Suturing Device

Stephanie M Novak, MS, Zachary Callahan, MD, Rod Avitia, Michael Ujiki, MD, FACS; NorthShore University Health System

We present a video of an endoscopic repair of a Dieulafoy Ulcer. The patient is a 73-year-old Hispanic female who presented multiple times with GI bleeding. She has a history of end-stage renal disease and is on hemodialysis. Her recurrent bleeds were initially diagnosed as a Mallory-Weiss tear. However, the chronicity of her symptoms led the surgical team to suspect another diagnosis, specifically a Dieulafoy lesion. During an upper endoscopy, a Dieulafoy lesion was identified and oversewn with 2-0 Demelene, using a figure-of-eight suture technique. Postoperatively, the patient is doing well and has had no recurrence of her GI bleeding since her May 2017 procedure.

V157

Laparoscopic Gastrojejunostomy Revision and Takedown of Gastrogastric Fistula

Sahil Gambhir, MD, James Nguyen, MD, Shaun Daly, MD, Brian R Smith, MD, Ninh T Nguyen, Marcelo W Hinojosa, MD; University of California Irvine Medical Center

Introduction: Although a gastrogastric fistula formation after a Roux-en-Y gastric bypass (RYGB) remains infrequent, the complications including weight gain remain prominent.

Methods: This is 60 year old male with a medical history of hypertension, obstructive sleep apnea, a previous RYGB and subsequent abdominoplasty, laparoscopic ventral hernia repair with mesh. After an initial 200 IB weight loss, he reported weight gain of greater than 60 IBs. A CT of A/P were obtained which revealed a large gastric pouch. An upper gastrointestinal study (UGIS) revealed an abnormal communication btw the gastric pouch into the remnant which was initially excluded. This was followed by an esophagogastroduodenoscopy which confirmed the large fistula. He was noted to be an appropriate surgical candidate and we proceeded with a laparoscopic gastrojejunostomy revision and takedown of gastrogastric fistula.

Results: The operation was completed as planned without intraoperative complications. Operative time took 4.5 hours. Blood loss was minimal. On postoperative day 1, he had an UGIS which was negative for leak and subsequently started on bariatric clears. He was discharged after postoperative day 3. He was seen in clinic several weeks later and reported a 46 IB weight loss.

Conclusion: We demonstrate a laparoscopic repair of a gastrogastric fistulas after open RYGB is feasible.

V158

Robotic Serra-Dorea operation for Recurrent Acalasia

Bruno Zilberstein, MD, PHD, FACS, Thiago Manesco, MD, Leandro Barchi, MD, PHD, FACS, Willy Petrini Souza, MD; Gastromed

Achalasia is a condition that affects 01 to 03 individuals in 100,000 and is consequent to denervation of the esophagus, compromising its peristalsis and relaxation of the lower esophageal sphincter (LES). From an etiological point of view in South America, mainly in Brazil, the most common cause is Chagas’ disease, with destruction of Meissner and Auerbach plexuses by Trypanosoma cruzi.

As complementary examinations, a barium radiograph (upper G.I.) constitutes the main diagnostic examination, and the upper endoscopy is performed to avoid an associated neoplasm.

When it comes to megaesophagus with a dolico megaesofaghus or a relapse of symptoms after Heller’s operation, reoperations are more complex to be accomplished.

Options are esophagectomy with gastroplasty or jejunal interposition. In Brazil, due to the large number os patients with advanced megaesophagus, the frequent failure of conservative treatment and to avoid esophagectomy, the Serra-doria operation was proposed in 1970.

This technique consists in Grondhal cardioplasty (latero-lateral esofagogastrostomy between the lower esophagus in the last 6 cm above the cardia and gastric fundus, close to the hiss angle) associated to partial gastrectomy with Roux-en-Y gastrojejunal reconstruction.

The Objective of this report is to show the application of this technique through a robotic minimally invasive access for the treatment of recurrent achalasia after Heller’s cardiomyotomy.

Conclusion: The use of robotic technology for reintervention on the esophagogastric junction facilitates its accomplishment and allows extremely complex procedures to be performed minimally invasively.

V159

Laparoscopic Excision of Epiphrenic Diverticulum with Heller Myotomy in an Octagenarian

Maria C Fonseca, MD, Cristian Milla, MD, Carlos Rivera, MD, Joel S Frieder, MD, Samuel Szomstein, MD, FACS, FASMBS, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Epiphrenic esophageal diverticulum is considered a false diverticulum as only compromises de mucosa and submucosa. Clinical manifestations appear when it achieves approximately 7.5 cm on diameter. We present a video of an 83-year old female with a longstanding history of GERD and high- grade dysphagia who was diagnosed with a 6 cm distal esophageal diverticulum. A laparoscopic resection of the diverticulum and Heller myotomy was safely performed. The patient had resolution of the dysphagia postoperatively.

V161

Robotic-Assisted Cholecystectomy and Non-Anatomic Liver Resection

Alexander L Marinica, DO, Lindsay Nelson, DO, Fazal Din Moghul, DO, Abubaker Ali, MD, FACS; Sinai Grace Hospital, Detroit Medical Center

This is a case presentation of a cholecystectomy and resection of a benign liver mass using the robotic platform. The patient is a 36-year-old female who was originally seen by a colleague surgeon for complaint of epigastric pain and nausea. Ultrasound showed cholelithiasis without signs of acute cholecystitis and 2 gallbladder polyps (5–6 mm). A pre-operative CT-scan was performed and read as normal, and an EGD showing gastritis and biopsy positive H. pylori. The patient was treated for H. pylori, but continued to be symptomatic. Thus, the patient was scheduled for cholecystectomy. Upon entering the abdomen, the surgeon noted a large mass (5 × 5 cm) adjacent to the gallbladder fossa in Segment 4. The procedure was aborted and the patient was referred to our clinic after a MRI-liver protocol was completed. The MRI showed a central scar most indicative of fibronodular hyperplasia (FNH), however, fibrolamellar carcinoma or adenoma were not excluded, and the previously described gallbladder polyps were also noted. Due to the gallbladder polyps, the continued symptoms and the liver mass, robotic assisted cholecystectomy and resection of the liver mass were discussed with the patient who was adamant about going forward with the procedure. Robotic excision was performed via a four-port (plus 2 assistant ports), transabdominal, transperitoneal approach. The final pathology was consistent with benign hepatocellular nodule (4.5 cm), surgically clear margins, and gallbladder with cholelithiasis and mild chronic cholecystitis, negative for malignancy. The procedure was completed in one hour and forty-one minutes with 50 cc of blood loss, and the post-operative hemoglobin remained unchanged on discharge on post-operative day 2. The patient was seen post-operatively at 2 weeks and 3 months, with no new complaints and complete resolution of her previous pain. This is a case demonstrating a safe resection of a liver mass using the robotic platform.

V162

Membrane Oriented Laparoscopic Lymphadenectomy Plus Complete Mesocolic Excision in Left Hemicolectomy

Hongming Li, Xinquan Lu, Dechang Diao, Xiaojiang Yi, Jin Wan; Guangdong Provincial Hospital of Chinese Medicine

Background: Complete mesocoloic excision (CME) has demonstrated to improve the long-term oncological outcomes. However, it remains the most technical challenging and time-consuming procedure because of its anatomical complexity. The authors provide a video to demonstrate laparoscopic left colectomy with CME following an optimal mesentery-defined approach with embryological and anatomical consideration.

Methods: The technique consists of four steps. First, the surgeon identifies the ‘‘tri-junction’’ in the sigmoid mesocolon area. This tri-junction is the fusion point of posterior sheet of descending mesocolon, the visceral peritoneum, and the prerenal fascia. The fusion fascia was incised at the promontory and mobilization was continued along the loose connective tissues. Second, the second ‘‘tri-junction’’ in the lateral peritoneal reflection area was identified. This tri-junction was the fusion point of the posterior sheet of descending mesocolon, the parietal peritoneum, and the prerenal fascia. The lesser sac was entered for the first time. Third, Transverse mesocolon was divided along the inferior pancreatic edge medial to lateral. The pancreatic body and tail was cover by the third sheet of omentum anteriorly and the fusion fascia of the fourth player of omentum and the anterior sheet of transverse mesocolon posteriorly. The lesser sac was entered for the second time. The left branches of MCA/MCV were clipped and cut. Finally, the fusion fascia of the first and second sheet of omentum was divided, and the gastro-colic ligament was cut at the same time. The omental bursa was opened wide for the third time preserving the gastroepiploic arcade. The transverse mesocolon was divided to the inferior pole of the spleen. The removal of the mesocolon with its intact mesocolic envelope completed the mesocolic excision.

Results: There were 8 males and 7 females with splenic flexure colon cancer underwent laparoscopic left hemicolectomy. There were no conversions to open surgery or serious intraoperative complications. The mean operative time was 181.5 ± 32.6 min, and blood loss were was 82.6 ± 41.8 ml. There was no recurrence at a mean follow-up period of 11.2 ± 5.3 months.

Conclusions: The mesentery-defined approach with the knowledge of embryological and anatomical consideration is safe and feasible for treatment of splenic flexure cancer.

Keywords: Splenic flexure cancer; Laparoscopy; Complete mesocoloic excision; left hemicolectomy

V163

Laparoscopic Appendectomy in Late pregnancy

Adel Alhaj Saleh, MD, MRCS, Mohanad Elshiekh, MD, Amir H Aryaie, MD, FACS; Texas Tech University Health Sciences Center

24 years old female G8P7 on 35th week of pregnancy presented to UMC for evaluation of right side abdominal pain and nausea for 1 day.

Surgery been consulted for evaluation of acute appendicitis.

Ultrasound findings were inconclusive

Vitals: Afebrile, HR 90 s BP 130/76

O/E: Alert and oriented, non toxic

Abdomen distended, Gravid uterus at the Xiphoid process. RLQ tenderness and rebound tenderness

Fetal cardiac activity checked before surgery was reassuring, Baseline 160, good reactivity with no deceleration

MRI revealed early acute appendicitis

Patient underwent successful laparoscopic appendectomy.

Fetal cardiac activity was checked in the OR right after finishing the procedure. HR 140–160, no decelerations .

Post operative course was complicated with abdominal pain.

Patient discharged home on POD # 6, seen in clinic in 1 week, doing well.

Patient underwent SNVD at 38w6d.

V164

Robotic laparoscopic assisted cystic duct ligation for persistent postoperative bile leak in Roux-en-Y gastric bypass patient

Baongoc Nasri, MD, PhD 1, Jordan Wilkerson, MD1, Jamie Schutle, MD1, Marius Calin2, Timothy Glass, MD1; 1St VincentHospital, 2Virtua Hospital

Introduction: Cystic duct leak is an uncommon complication following cholecystectomy. Endoscopy is considered safe and effective therapy. However, ERCP in post gastric bypass can be technical challenges. Robotic assisted cystic duct exploration can be an option for cystic duct leak management even at delayed presentation.

Purpose: this is the first case report of delayed repair of persistent cystic duct leak with robotic assisted cystic duct exploration in patient with history of gastric bypass who failed percutaneous interventions.

Materials and Methods: This is a 72 year old female with remote history of gastric bypass who underwent laparoscopic cholecystectomy for acute gangrenous calculus cholecystitis. CT scan and HIDA scan on POD 5 confirmed bile leak. She underwent percutaneous drainage of biloma on POD6, then percutaneous external biliary stent placement on POD 10. Cholangiogram on POD 10 showed persistent cystic duct leak. She has persistent high drain output. However, she denied trial of trans-gastric ERCP. She was transferred to our hospital for further intervention. She underwent robotic assisted cystic duct exploration 8 weeks after the surgery. After pneumoperitoneum via Veress needle, the first 8 mm port was inserted at left subcostal margin. Three additional 8 mm ports were n at left medial mid abdomen, supra umbilicus and right medial lower abdomen. The robot was docked at reverse Trendelenburg. Bipolar was docked at arm 1, scissor at arm 3, camera at arm 2. After extensive adhesiolysis, ultimately the previous clips were found from the previous cholecystectomy. There was no evidence of bile leak on initial inspection, including the use of Firefly technology. Patient received 7.5 ml Indocyanine green prior to coming into the operative suite. Further dissection was carried cephalad where we were able to identify the right hepatic duct. We then continue dissection distally and ultimately the only areas that were felt to be responsible for the leak were 2 small luminal structures near the old clips. Each of these was clipped with Hem-o-lok clips. A complete intraoperative cholangiogram through the transhepatic drain showed no cystic duct leak, contrast in the duodenum and bilateral intrahepatic duct.

Results: Her JP drain was removed POD 5 on the day of discharge. She was seen in the office and recovered well.

Conclusions: This technique has not been previously described in the literature. Robotic assisted cystic duct ligation is a new approach for persistent cystic duct leak. Robotic flexibility enables complex adhesiolysis even at delayed postoperative presentation.

V165

Robotic Toupe Fundoplication for Type 2 Hiatal Hernia Complicated by Retained Needle

Lindsay Nelson, DO, Alexander Marinica, DO, Fazaldin Moghul, DO, Abubaker Ali, MD, FACS; Detroit Medical Center/Sinai-Grace Hospital

Introduction: Robotic toupe fundoplication is an accepted treatment for symptomatic hiatal hernias. A retained needle is a feared complication of minimally invasive surgery and no single accepted best practice exists for retrieval. In this case report, a lost needle is ultimately determined to be within the chest cavity after robotic abdominal surgery.

Case Presentation: 78 year old female with nausea and vomiting as well as pulmonary embolism after a knee replacement is found to have an obstructing type two hiatal hernia. Work-up demonstrated a gastric outlet obstruction secondary to volvulus. She underwent a robotic toupe fundoplication using the SI platform. Needle count at the conclusion of the procedure was one needle short. Robotic exploration, laparoscopic exploration with spleen mobilization, and left VATS were performed without successful retrieval. The procedure was concluded with the retained needle left in place. The patient recovered from surgery without any longterm complications to date. She remains asymptomatic, electing to forego further intervention to obtain the retained needle.

Discussion: Storing needles in the diaphragm during robotic surgery can increase the risk of retention, though no known cases to date have reported the loss of a needle through the diaphragm into the chest cavity. Proposed exploration via open laparotomy is one of the common options for locating a retained needle. In this case, laparotomy would have been unnecessary and unsuccessful, as post-operative CT scan demonstrated the needle within the costophrenic sulcus. The attached video abstract demonstrates the performed procedure and details the case of a lost needle in the left chest cavity and attempted localization. Practice changes will include removal of each needle after its use, rather than placing needles in the diaphragm intraoperatively to await mass removal at the conclusion of the procedure.

V166

Laparoscopic Cholecystectomy, Paraesophageal Hernia Repair, and Roux-en-y Gastric Bypass

Michelle Estrada, MD, Adel Alhaj Saleh, MD, MRCS, Amir H Aryaie, MD, FACS; Texas Tech University Health Sciences Center

Case Background:
  • 48-year-old morbidly obese female with 2-year history of worsening shortness of breath and chest tightness

  • Associated dysphagia, vomiting, heartburn, and inability to lay flat.

  • Episodic right upper quadrant pain.

  • Referred to surgery by Thoracic surgeon after a large paraesophagealhernia was found on chest CT

Medical and Surgical History:
  • Obesity, BMI 40

  • GERD

  • Hashimoto’s disease

  • Cesarean Section

  • Cholelithiasis

EGD findings:
  • Barrett’s esophagus

  • Large paraesophagealhernia

CT scan Findings:
  • Large paraesophageal hernia and multiple gall stones.

Procedures performed:
  • Laparoscopic cholecystectomy

  • Laparoscopic paraesophagealhernia repair with Bio mesh

  • Laparoscopic Roux-en-Y gastric bypass for morbid obesity and as an anti-reflux procedure

Post-operative Course:
  • Upper GI series on post-operative day 1 was negative for extravasation and started on clear bariatric diet

  • Discharged on post-operative day 2

  • Recovering well on 1-week and 6-week post-op visits.

In Conclusion:
  • Laparoscopic cholecystectomy, paraesophagealhernia repair and gastric bypass can be done safely and simultaneously

  • The gastric bypass served as a weight loss and anti-reflux procedure.

V167

Robotic Assisted Splenectomy

Fazaldin Moghul; DMC Sinai Grace Hospital

Case Report Video Abstract: 50 year old female with a 6.3 cm splenic cyst causing nausea and abdominal pain. Underwent robotic assisted splenectomy with minimal blood loss and 43 minutes robotic console time. Robotic splenectomy is a safe and appropriate approach for patients with tumors or are at risk for bleeding.

V168

Robotic Assisted Sleeve Duodenectomy for D4 Duodenal Adenocarcinoma

Spencer M Mossack, MS1, Joseph Kim, MD2, Aaron R Sasson, MD1, Georgios V Georgakis, MD, PhD 1; 1Stony Brook University, 2University of Kentucky

We are presenting a robotic assisted sleeve duodenectomy for a D 4 duodenal adenocarcinoma

Patient is a 72 year old male who presented with recurrent GI bleed with anemia.

He was on Eliquis for paroxysmal atrial fibrillation. Prior work up was unable to identify the source of bleeding. Push enteroscopy showed a large, friable proximal jejunal ulcerated mass. Pathology was consistent with moderately differentiated invasive adenocarcinoma. CT scan excluded the presence of metastatic disease.

During surgery, a suspicious lesion on segment 2 of the liver was excised and sent for frozen section. It came back negative. With arm 3 we pulled the stomach anteriorly and we entered the lesser sac through the gastrocolic ligament. The avascular plane was dissected to identify the posterior stomach. This plane was followed to the right upper quadrant and further towards the hepatic flexure.

The patient had a prior cholecystectomy and he had adhesions in this area. We performed a Cattell Braasch maneuver medializing the right colon as much as possible. Next, we performed a Kocher maneuver, focusing on the distal second and third part of the duodenum. Once the duodenum was freed from its retroperitoneal attachments, we were able to take down the ligament of Treitz from the right side. The proximal jejunum was pulled in the right upper quadrant and was divided with an laparoscopic stapler. The proximal jejunum mesentery was then divided with a vessel sealing energy device towards the pancreas. Care was taken to protect the small bowel mesentery and especially the superior mesenteric artery and vein. The last fibers of the ligament of Treitz were taken with an energy sealing device and the third part of the duodenum was separated from the pancreas.

The freed third part of the duodenum was divided from the second part with an laparoscopic stapler. Care was taken to stay away from the pancreatic ampulla. An isoperistaltic duodenojejunostomy was created using a 60 mm laparoscopic stapler. The common enterotomy was closed with a 2 layer running 3-0 Monocryl V Lock suture starting from the inferior part of the opening. This is very important because the inferior part of the common enterotomy is very difficult to visualize if the suture starts from the superior part of the enterotomy. Finally, viability and good perfusion of the anastomosis was verified with Indocyanine Green and fluorescent imaging in situ.

V169

Robotic-Assisted Partial Ampullectomy & Common Bile Duct Sphincteroplasty as Treatment for Sphincter of Oddi Dysfunction

Jordan Wilkerson, MD, Bianca Kenyon, MD, Jessica Belchos, Kyle Seudeal, MD, Kirpal Singh, MD; St. Vinent Hospital

This is a video abstract submission demonstrating robotic partial ampullectomy with biliary sphincteroplasty in a patient presenting with type 3 Sphincter of Oddi dysfunction that has previously failed multiple treatment modalities. The patient presented is a 39 year-old female who has undergone multiple ERCPs with sphincterotomy, botox injection, and stent placement with only transient symptomatic improvement. The feasibility of treating this patient with ampullectomy and sphincteroplasty via a minimally invasive approach is presented.

V170

Laparoscopic double-flap technique after proximal gastrectomy for gastrointestinal stromal tumor in the esophagogastric junction

Wei Wang; Guangdong Provincial Hospital of Chinese Medicine

Laparoscopic surgery for gastric gastrointestinal stromal tumors (GISTs) is now widely performed. However, laparoscopic resection of GIST in the esophagogastric junction (EGJ) is technically difficult and rarely reported. When the tumor invaded the esophagogastric line or if the cardia integrity could not be maintained during local resection, laparoscopic proximal gastrectomy was performed. Herein, we reported a laparoscopic proximal gastrectomy with double-flap technique to prevent reflux.

Firstly, the gastrocolic omentum and splenogastric ligament were separated with the gastric greater curvature and fundus mobilized. The left gastric artery was ligated. The lesser curvature and lower esophagus were mobilized. The esophagus was transected laparoscopically.

Secondly, a mini midline incision was used to transect the stomach. The double seromuscular flaps (2.5 cm wide * 3.5 cm high) were cut at the anterior wall of the gastric remnant to cautiously separate the submucosal layer and expose the mucosa.

Thirdly, after creation of the double flap, the inferior end of the mucosal window was cut laparoscopically, and the posterior wall of the esophagus was fixed to the superior edge of the mucosal window. Continuous suturing was performed between the posterior wall of the esophagus and the superior window of the mucosa on the remnant stomach, as well as between the anterior wall of the esophagus and gastric wall at the lower end of the flap. Finally, the anastomosis was fully covered by the seromuscular flaps using continuous suturing [1].

After the anastomotic procedure, intraoperative endoscopy was regularly performed to check the anastomosis.

Reference

[1] Hayami M, Hiki N, Nunobe S, Mine S, Ohashi M, Kumagai K, Ida S, Watanabe M, Sano T, Yamaguchi T. Clinical Outcomes and Evaluation of Laparoscopic Proximal Gastrectomy with Double-Flap Technique for Early Gastric Cancer in the Upper Third of the Stomach. Ann Surg Oncol. 2017 Jun;24(6):1635–1642.

V171

Beyond the limits of laparoscopic surgery: robotic subtotal pancreatectomy

Carter Powell 1, Christine Schammel, PhD2, Steven D Trocha, MD3; 1Kenyon College, 2Pathology Associates, 3Department of Surgery, Greenville Health System

Laparoscopic distal pancreatectomy (LDP) has proven to be superior to the traditional open approach due to its minimally invasive nature. However, technical limitations still exist when utilizing a laparoscopic approach. Dexterity achieved with robotics overcomes laparoscopic limitations, allowing surgeons more delicate, technically demanding and proximal dissections. We present a subtotal distal pancreatectomy performed robotically. The patient is a 64-year-old white male who presented with right abdominal pain that extended to his right groin. CT and MRCP imaging identified a dilated pancreatic duct into the junction of the head of the pancreas, suggesting an intraductal mucinous neoplasm of the main duct (IPMN) extending into the head of the pancreas. The optimal course of action was determined to be resection of the pancreas using a completely robotic approach. The robotic approach allowed for optimal vessel dissection and division, ultrasound identification, tissue manipulation and positioning, duct dissection and division, and oversewing of the pancreatic duct with minimal blood loss and post-operative recovery. The case emphasizes the advantages of the robotic approach for distal pancreatectomy allowing for precise dissection in a significant procedure and how this innovative technology can the overcome technical limitations of a laparoscopic approach.

V172

Laparoscopic Trans-peritoneal Pyelolithotomy for a Large Ectopic Pelvic Renal Calculus

Manish Kumar Gupta, Associate Professor, Sarrah Idrees, Dr, Rathindra Sarangi, Dr; Sir Ganga Ram Hospital, New Delhi

Objective: Renal ectopia is a rare congenital anomaly which results in improper ascent of kidney during their embryonic development. Tortuous & high insertion of ureter leads to urinary stasis. Pelvic location of kidney, variation of pelvicaliceal system (PCS) anatomy, stone size and location make the management challenging. ESWL, PCNL and laparoscopic trans-peritoneal pyelolithotomy are the treatment modalities described in literature. We report a case of a huge symptomatic urolithiasis in right ectopic kidney which was managed successfully by laparoscopic trans-peritoneal approach.

Case Report: A 57 years male patient presented with history of episodic pain in lower abdomen for last 6 months which was not associated with dysuria, hematuria or any other abdominal symptoms. X ray abdomen, Ultrasonography & CT report revealed right ectopic kidney with large right extra renal pelvis having calculus of size 4.4 × 3.7 cm in renal pelvis. Delayed scan revealed evidence of adequate excretion of contrast & complete opacification of right ureter. CT angiography reported two renal arteries.

Laparoscopic trans-peritoneal pyelo-lithotomy was done successfully. A 4 cm large speculated calculus was present almost occupying the whole of the pelvis and was densely adherent to the pelvic mucosa. The pelvis and ureter was flushed with the help of 6Fr catheter after removal of stone. The pyelotomy was closed with Vicryl 3-0 continuous suture & 24 Fr tube drain was placed in the pelvis. Patient was discharged and drain was removed on 3rd and 5th postoperative day respectively.

Discussion: ESWL is the treatment option for stone size < 2 cm in pelvic kidney with 54% success rate and causes more pain in post-operative period. Risk of injuring the bowel or vessels is always there in percutaneous access because of ectopic position of kidney. Laparoscopic management is better alternative for failed ESWL or stone of > 2 cm size. Laparoscopic pyelotomy provide safe access to pelvis and also avoid any visceral and vascular injury. The ureteric catheter used for flushing and was taken out before closing the pyelotomy which ultimately prevent multiple sessions of interventions.

Conclusion: Laparoscopic trans-peritoneal approach should be a preferred approach for managing urolithiasis in ectopic pelvic kidney as it is a safer option which decreases the morbidity and makes patient stone free in single session.

V173

A complex hiatal hernia repair following open gastric banding with concomitant incisional hernia repair

Satya S Dalavayi, MD, John S Roth, MD; University of Kentucky

A 62 year old female with history of gastric banding and incisional hernias presented to clinic with belching, dysphagia, reflux, and emesis. She was diagnosed with a symptomatic hiatal hernia and ventral hernias. She underwent a complex open hiatal hernia repair with gastric band excision and concurrent ventral hernia repair. She tolerated the surgery well and experienced an improvement in symptoms and presentation following surgery.

V174

Mesentery Oriented Laparoscopic Radical Distal Gastrectomy for Gastric Cancer: Is it more in line with the principle of oncology?

Dechang Diao, MD, Xinquan Lu, MD, Xiaojiang Yi, MD, Hongming Li, MD, Jin Wan, MD; Department of Gastrointestinal (Tumor) Surgery, Guangdong Province Hospital of Chinese Medicine, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine

Background: In recent years, with the further study of the metastasis of gastric cancer and the improvement of the understanding of gastric mesangial anatomy, many scholars have come to realize that D2 procedure based on lymphatic adipose tissue dissection may not be enough. The concept of operation based on mesenteric anatomy is proposed. Herein, we described a "mesentery oriented" approach for Laparoscopic radical distal gastrectomy (mo-LRDG) for Gastric cancer.

Methods: Clinical data of 108 cases of LRDG for gastric cancer from January 2017 to May 2018 were analyzed retrospectively. 54 cases were included in the mo-LRDG group, which was compared with 54 cases with conventional standard approach (cs-LRDG). For mo-LRDG group, our method was to lift the dorsal mesentery of the stomach, and show the Tri-junction between the dorsal mesentery and the transverse colon for cutting off the membrane bridge and expanding to the right in the confluent fascial space. We exposed and resected at the root of the right mesentery of the gastroepiploon, and cleared the lymph nodes (LNs) of NO.11d and NO.4sa. Continue to expand to the right of Tri-junction, the right mesentery of gastric omentum was cut off at the root, and NO. 6 LNs were removed. To the left, NO.7, 8a, 9 LNs were cleared from the left mesentery and the roots were severed. NO.5 LNs were cleared by exposing the right mesentery. The NO.1 LNs were removed by the naked proximal stomach. Finally, we took a 5-cm auxiliary incision on the upper abdomen for B-I anastomosis.

Results: The mean operation time was without statistical significance between the mo-LRDG and cs-LRDG groups (181.5 vs 185.3 min, p > 0.05) and it was the same with the mean blood loss (105.4 vs 107.5 ml, p > 0.05). The mean number of harvested LNs was 29.3 in mo-LRDG group, compared with 26.2 in cs-LRDG group (p = 0.06). There were 2 cases of conversion in mo-LRDG group and 3 cases in cs-LRDG group. Postoperative hemorrhage was occurred in 1 patients in both groups (p > 0.05), and no post-operative mortality was observed.

Conclusion: The initial results suggest that the "mesentery oriented" approach for mo-LRDG may be a feasible and safe procedure. It may have some advantages in postoperative recovery and lymph nodes harvest.

Key words: Mesentery Oriented; Laparoscopic Radical Distal Gastrectomy; Gastric cancer

V175

Robotic Excision of High Grade Leiomyosarcoma

Iswanto Sucandy, MD, Sharona B Ross, MD, FACS, Thaeri Cortes, BS, Janelle Spence, BS, Alexander S Rosemurgy, MD, FACS; Florida Hospital Tampa

Introduction: Leiomyosarcoma is an uncommon soft tissue malignancy associated with poor prognosis. In the literature, only few cases of localized small leiomyosarcoma have been described. Most abdominal leiomyosarcoma is resected through traditional “open” operation. Robotic technique offers many technical advantages over “open” operation and conventional laparoscopy. We aim to report our approach of minimally invasive robotic resection of leiomyosarcoma.

Methods: A preoperative CT scan showed 5.5 cm PET avid mass in the porta hepatis, portal hypertension, cavernous transformation of portal vein, and 1 cm arterially enhancing segment 6 liver mass. The operation was undertaken using a robotic system with 5 port technique. Robotic ultrasound was used to systematically examined the liver. The segment 6 liver mass was ablated using microwave technology.

Results: 66 year old man presented with constant dull epigastric pain and 12 lb weight loss. The background liver is only minimally cirrhotic. Percutaneous needle biopsy showed sarcomatoid/spindle cell carcinoma. The porta hepatis mass was located in the gastrohepatic space, anterior to the caudate lobe and inferior vena cava. Circumferential dissection was carefully undertaken using robotic bipolar forceps and hook cautery while avoiding injury to the common hepatic artery and coronary vein located nearby. Laparoscopic retrieval bag was used to remove the specimen. Operative time was 120 min with 50 cc of estimated blood loss. No intraoperative complications were seen. Patient had an uneventful postoperative recovery with 2 days of hospital stay. Final pathological report showed high-grade leiomyosarcoma (> 50 mitosis per 10 high power fields) and the resection margins were negative for malignancy or neoplasia.

Conclusions: Robotic approach for resection of leiomyosarcoma is safe and feasible in select cases, even in the setting of portal hypertension. Reported technology extends the application of minimally invasive technique in complex abdominal operation.

V176

Laparoscopic Repair of Hiatal Hernia after Esophagectomy

James Nguyen, MD, Luke Putnam, MD, Sahil Gambhir, MD, Brian Smith, MD, Ninh Nguyen, MD; University of California Irvine Medical Center

We present a case of a laparoscopic repair of a hiatal hernia after prior esophagectomy.

Our patient is a 61 year old male with stage III Esophageal Cancer who underwent neoadjuvant chemoradiation followed by laparoscopic and thoracoscopic esophagectomy. He presents to us five months post operatively with complaints of dysphagia.

CT scan demonstrated a large hiatal hernia with transverse colon in the hernia sac. The patient was scheduled for elective repair.

Post operatively, UGI study showed no residual hernia with adequate passage of contrast through the gastric conduit. Our patient did well and was discharged on post operative day 1.

V177

Trans anal endoscopic microsurgery for early rectal cancer and high grade dysplasia. Full thickness resection of flat lesions non resectable by endoscopic therapy.

Ayermin Vargas Salgueiro, MD 1, Fernando Leal Hernandez, MD1, Ulises Barraza Reyes, MD1, Luis Leal Del Rosal, MD, FACS, FRCSC2; 1Christus Muguerza, 2UNIMECID

Colorectal cancer is one of the leading cause of dead and one of the most common cancers of the GI tract.

Increasing detection of early stage colorectal cancers have demanded development of minimally invasive procedures like endoscopic mucosal resection and for tumors non amenable for endoscopic therapy, transanal endoscopic microsurgery is an alternative to a more radical resection for appropriately selected tumors, besides it is superior to ablative therapies that does not provide specimen for histopathology.

We present the resection of two cases of flat lesions detected by colonoscopy located en the middle and distal thirds of the rectum diagnosed as villus polyp with high grade dysplasia that could not be resected by colonoscopy. Both of them were located at 5 and 6 cm from the anal verge.

Transanal endoscopic microsurgery was performed.

Technique. A lone star retractor and gel point device were used un order to establish pneumorectum. Both flat polyps were found in middle and distal rectal wall, using a combination of electrosurgery and advanced surgical device, circumferential and full thickness rectal wall resection of sessile polyps were achieved. Histopathology showed hidden adenocarcinoma in one of cases. Patients showed uneventful recovery and discharged home the day after the procedure. Transanal microsurgery is an alternative to a more radical resection in selected rectal tumors, that are non amenable by endoscopic (colonoscopy) resection or submucosal disection because of the size of the polyp and the closeness to the anus.

V178

Robotic Completion Cholecystectomy Following Unsuccessful Operative Intervention For Severe Acute Cholecystitis

Jordan A Wilkerson, MD, Cory Banaschak, DO, Jessica Belchos, MD, Bianca Kenyon, MD, Kyle Suedeal, MD, Kirpal Singh, MD; St. Vincent Hospital

This is a video abstract submission detailing a robotic completion cholecystectomy in a 56 year-old female that was performed for recurrent subhepatic abscesses and chronic symptoms following unsuccessful operative intervention for initial severe acute cholecystitis. The patient had previously undergone attempted laparoscopic cholecystectomy necessitating conversion to a laparotomy with eventual termination of the procedure with simple drain placement due to a significant inflammatory response limiting adequate visualization of anatomy. A robotic cholecystectomy was thus able to be successfully performed without complication or prolonged operative time.

V179

Robotic Right Hepatectomy using monopolar energy: Perfecting the procedure without using advanced energy instruments.

Ali Ahmad, MD, FACS; University of Kansas School of Medicine-Wichita

Robotic surgery has shown significant promise in the hepatobiliary specialty. Traditional hepatectomy routinely entails the use of advanced energy instruments. We present a novel approach to minimally invasive formal hepatectomy using the DaVinci Xi system. Use of standard monopolar and bipolar robotic instruments, without advanced energy instruments, can be safely used to achieve a high quality resection with potential cost reduction benefits.

We present a case of a 54 year old female diagnosed with a symptomatic giant right hepatic adenoma measuring approximately 20 cm in size. Due to the large size of the lesion, a right hepatectomy was considered appropriate. Patient underwent an uneventful robotic right hepatectomy. Estimated blood loss was 75 mL. No complications occurred in the postoperative period. Patient was discharged home on postoperative day 5.

In our experience, robotic formal hepatectomy is a safe procedure that grants accelerated postoperative recovery. The procedure can be performed with simple monopolar and bipolar energy which likely eliminates the need for more cost-prohibitive advanced energy instruments.

V180

Management of various rectal lesions by using TAMIS

Pramod Nepal, MD, Shinichiro Mori, MD, PhD, Yoshiaki Kita, MD, PhD, Kan Tanabe, MD, PhD, Kenji Baba, MD, PhD, Yasuto Uchikado, MD, PhD, Hiroshi Kurahara, MD, PhD, Takaaki Arigami, MD, PhD, Masahiko Sakoda, MD, PhD, Kosei Maemura, MD, PhD, Shoji Natsugoe, MD, PhD; Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University

Transanal Minimally Invasive Surgery (TAMIS) is a hybrid of Transanal endoscopic microsurgery (TEM) and single-port laparoscopy. It is a feasible alternative to TEM, provides the same benefits at a fraction of the cost. We performed TAMIS for different rectal lesions in total 9 cases (2 GISTs, 3 Ulcerative colitis, 1 anastomotic rectal stenosis, 1 FAP, 2 Stage-I rectal cancer) in our university hospital.

This video demonstrates the TAMIS procedure in the management if two different cases. The first case is anastomotic rectal stenosis and the second one is rectal adenoma accompanied by hemorrhoids.

V181

Robotic Multiple Resection for Gastric Adenocarcinoma

Valentina Valle, MD, Alberto Mangano, MD, Roberto Bustos, MD, Gabriela Aguiluz, MD, Pier Cristoforo Giulianotti, MD, FACS; University of Illinois at Chicago

Introduction: 52 years old man, cigarette smoker, complaining of intermittent abdominal pain and 5 lb weight loss. EGD: non bleeding gastric ulcer. Pathology report on biopsies: gastric adenocarcinoma with H. pylori Gastritis. Past Medical and Surgical History: negative.

Methods and Procedures: Robotic Total Gastrectomy with en-block distal Splenopancreasectomy, left Adrenalectomy, D2 Lymphadenectomy and Omentectomy. After the isolation of the esophagogastric junction and the exploration of the Lesser sac, the gastric fundus is exposed and it appears to be fused to the pancreatic tail. Hence, an en-block resection is performed. The right gastroepiploic vessels and the right gastric artery are divided. Linfoadenectomy along the hepatic artery and the celiac trunk. The left gastric artery is divided by a vascular stapler. After the transection of the splenic artery, the pancreas is separated from Gerota capsule and the pancreatic tail and splenic vein are divided. An adrenalectomy is performed to maintain an oncologically radical resection. The left adrenal vein is divided between suture of 4-0 Prolene and the adrenal gland is separated from the kidney upper pole. The specimen is completely removed en block and it includes the stomach, the omentum, the pancreatic tail, the spleen and the left adrenal gland. Undocking. Specimen extraction by a small midline incision and a Roux-en-Y anastomosis with stapler and PDS 3-0 is performed. Redocking. Manual end-to-side esophagojejunostomy with double layer 3-0 Prolene was completed and tested.

Results: Operative Time: 263 min. Blood loss: 100 cc. Discharge in the 7th POD. Uneventful post-operatory course. Permanent pathology: Infiltrating Poorly differentiated Grade 3 Gastric Adenocarcinoma (4.3 × 3.4 × 0.4 cm), invading the splenic capsule and the peri pancreatic adipose tissue, with metastasis to the adrenal gland. (pT4b, pN1, pM1). Resection margins tumor free.

Conclusion: Complex multiorgan resections are technically feasible and safe if performed in high volume and high expertise centers. The reduced blood loss (no transfusion needed in this case), the short hospitalization with a good quality of life allow a short time between surgery and the beginning of the oncological treatment. The robotic platform offers several advantages, including 3D vision, superior instruments dexterity and better ergonomy. Robotic technology may became surgeon’s preferred treatment modality and potentially it may extend the boundaries of the minimally invasive approach to increasingly more challenging scenarios.

V182

Minimally invasive approach for excision of giant adult mesenteric lymphangioma

Varun Jain, MD, Daniel H Rhee, MD, David Pearson, MD, James Madura, MD, Chee-Chee Stucky, MD; Mayo Clinic Hospital, Phoenix

Here we present an operative video for the case of a young adult male who presented with fairly rapid onset and worsening of his abdominal symptoms caused due to a giant mesenteric lymphangioma, managed safely via a laparoscopic approach. The video outlines, a step by step approach to proceed with careful dissection and complete surgical excision of the large cyst.

Background: Lymphangiomas are rare congenital lymphatic malformations, usually occurring in children, uncommon in adults. They usually involve the neck and axilla with abdominal lymphangiomas being rare (< 5%). When they are abdominal, sites involved are retroperitoneum, mesentery of intra-abdominal viscera, omentum with varying frequencies. Etiology is unclear, usually considered congenital, but other causes may be-trauma, lymphatic obstruction, surgery, or other inflammatory process, radiation. Clinical presentation is usually subtle and non-specific but may cause obvious symptoms due to mass effect when large. They may even have more serious complications such as rupture, bleeding, infection, torsion or bowel obstruction. Imaging (US, CT) can suggest a diagnosis, but definitive diagnosis is after histo-pathological examination following complete surgical resection. Other treatment modalities such as percutaneous drainage, injection of sclerosant, marsupialization can be attempted for high risk surgical candidates. Recurrence averages around 6% (ranging from 0 to 13%). Surgical technique may be either open or laparoscopic, with minimally invasive surgery offering an obvious cosmetic advantage with quicker recovery, however being technically challenging, especially for larger cysts.

Surgical technique may be either open or laparoscopic, with minimally invasive surgery offering an obvious cosmetic advantage with quicker recovery, however being technically challenging for larger cysts. Here we present a young male with fairly rapid onset and worsening of his symptoms caused due to a giant mesenteric lymphangioma, managed safely via a laparoscopic approach.

V183

Heterotopic Pancreas Discovered During Sleeve Gastrectomy

Nancy Panko, MD 1, Gerrit Dunford, MD2, Kenneth Copperwheat, DO2, Rami Lutfi, MD2; 1Houston Northwest Medical Center, 2Saint Joseph Hospital

Introduction: Heterotopic pancreas is rare, with few reports in the literature. We describe a patient undergoing bariatric surgery with an incidentally discovered gastric mass. After resection, this mass proved to be heterotopic pancreas.

Case: Patient is a 35 year old woman with morbid obesity and lap band placement. She underwent removal of the lap band for complaints of dysphagia, and underwent bariatric workup, including preoperative EGD. She had no abnormal findings and elected to proceed with sleeve gastrectomy.

On the operating room, she was found to have a 3 cm exophytic mass near the lesser curvature of the stomach. We performed intraoperative endoscopy and did not appreciate any mucosal involvement. We did not biopsy the mass, as we did not want to seed the abdomen if this proved to be a malignancy. The mass was near the incisura, and there was concern that performing the sleeve and resecting the mass with the stomach remnant would create too narrow a sleeve. We aborted the procedure and brought the patient back to the clinic to discuss the findings.

After discussing management options with the patient, we decided to move forward with gastric bypass and resection of the mass. The patient was taken to the operating room. We created our gastric pouch by first identifying the mass and then creating a window into the lesser sac 5 cm below the GE junction. We then constructed a vagal sparing gastric pouch staying superior to the mass. We evaluated the mass within the gastric remnant and performed a wedge resection using two staple loads. We were able to obtain clear margins grossly. This was sent to pathology for frozen section, and did not show evidence of malignancy. We inspected the posterior wall of the remnant to ensure that there were no other occult masses and there were none. We completed the bypass and performed completion endoscopy, which was normal.

Final pathology revealed heterotopic pancreas. The patient recovered from surgery without difficulty and has been doing well postoperatively.

Discussion: Heterotopic pancreas is defined as pancreatic tissue with devoted vascular and ductal structures in the GI tract without continuity to the pancreas. They are most commonly found in the stomach and can be asymptomatic, although occasionally can cause inflammation, bleeding, or infection. They grossly appear similar to gastrointestinal stromal tumors, carcinoids, and lymphoma. Although rare, heterotopic pancreas should be considered in the differential for extramucosal gastric tumors.

V184

Laparoscopic Sleeve Gastrectomy with concurrent repair of an incidental incarcerated Morgagni Hernia

C Hassan, LF Gonzalez Ciccarelli, A Gangemi, M Masrur, F Bianco, P Quadri, L Sanchez-Johnsen, P Giulianotti; University of Illinois at Chicago

Introduction: Morgagni hernia is congenital diaphragmatic defect presenting most commonly in children and extremely rare in adults. This hernia is most often asymptomatic and diagnosed incidentally. When symptomatic this hernia is associated with abdominal pain, discomfort, loss of appetite and chronic respiratory symptoms.

Methods and Results: We present a case of a 31-year-old female with a BMI of 53.2 kg/m2 and a past history of obstructive sleep apnea with no past surgery presented to clinic seeking bariatric surgery after reporting a lifelong history of obesity. Patient underwent fluoroscopy that showed normal esophagogram with a negative hiatal hernia and an enlarged cardio-mediastinal silhouette. The patient was elected to undergo laparoscopic sleeve gastrectomy. Diagnostic laparoscopy was performed and an incidental finding of a Morgagni hernia was diagnosed. A significant section of the transverse colon was incarcerated in the diaphragmatic defect. The content was carefully reduced laparoscopically. Hernia content was directly in contact with the pericardium. The pericardium was visualized at the midline and the distal stomach and pylorus were identified. The hernia measured approximately 8 cm. Primary repair of the hernia was performed with interrupted non-absorbable 0 sutures. Mobilization and dissection of the greater curvature was then performed using a stapler in order to create the gastric sleeve, 8 cm proximal to the pylorus and 1 cm to the left angle of His. A 40 French Bougie was used to size the lumen. Intraoperative air leak test was negative. Overall operative time was 162 minutes with an estimated blood loss of approximately 50 ml. Postoperative course was uncomplicated. Patient was discharged tolerating liquid diet on postoperative day three. At 3-month follow up, patient was doing well, tolerating full diet with no dyspnea or signs of recurrence and an excess weight loss of 27%.

Conclusion: Simultaneous Laparoscopic Sleeve Gastrectomy and Morgagni hernia repair is safe and feasible surgery in experienced hands.

V185

Laparoscopic Intragastric Resection via Combined Laparoendoscopic Technique with Mucosal Closure

Alexandra W Elias, MD, Timothy A Woodward, MD, Steven P Bowers, MD; Mayo Clinic FL

This video demonstrates laparoscopic intragastric resection via combined laparoendoscopic technique with mucosal closure.

A 43-year-old female underwent an upper endoscopy for chronic nausea, and a submucosal tumor was revealed in the gastric cardia, just distal to the gastroesophageal junction. Endoscopic ultrasound and fine needle aspiration were consistent with a 2.7 cm leiomyoma. CT demonstrated the mass abutting the GE junction without evidence of metastasis.

Laparoscopic intragastric resection was planned.

After the induction of general endotracheal anesthesia, the patient was placed supine.

An infraumbilical Hasson cannula was placed for exploratory laparoscopy, which demonstrated no sign of metastatic disease. A 5 mm port was placed to allow exposure of the anterior stomach by moving the omentum.

Endoscopy was performed to visualize the mass.

The abdomen was desufflated, and three one-step dilating ports were placed into the stomach through the abdominal wall.

An endoloop was used to lasso the mass to allow easier dissection, and the plane was initiated using an endoscopic retroflexed hook knife.

Initially we felt the dissection could be accomplished endoscopically with the assistance of laparoscopic intragastric retraction; however, due to concern for muscular involvement, we decided to use the larger laparoscopic hook on electrocautery for dissection.

We were able to enucleate the mass from the muscle, preserving the gastric sling fibers, by using the back of the hook to bluntly push muscle fibers away and the tip of the hook to deliver punctate cautery to lyse connections to the mass, taking care not to rupture the capsule.

Once the encapsulated mass was freed, it was placed into a Roth net and retracted flush against an endoscopic overtube, then removed through the mouth.

A 3-0 barbed suture was used to close the mucosal defect transversely, taking small bites of muscle to close the space.

The one-step trocars were exchanged for balloon-tipped trocars, and interrupted silk suture was used to closed the gastrotomy sites in a Witzel suture fashion.

The omentum was then replaced over the stomach.

The stomach was externally examined at the hiatus before repeating endoscopy, which confirmed our mucosotomy was closed securely and that there was no leakage from our gastrotomy sites.

Pathology revealed at 2.5 cm benign leiomyoma.

Upper GI study on postoperative day one demonstrated contrast flowing freely from the esophagus through the stomach without evidence of leak. The patient tolerated a blenderized diet and was discharged home.

V186

Laparoscopic D2 gastrectomy with therapeutic para-aortic lymph node dissection for advanced gastric cancer

Wei Wang; Guangdong Provincial Hospital of Chinese Medicine

Patients with advanced gastric cancer and locally enlarged para-aortic lymph nodes were selected for this study. They were all received a neoadjuvant chemotherapy. If the curative effect was at least partial response, then the patient would underwent laparoscopic D2 gastrectomy with para-aortic lymph node dissection.

After a standard laparoscopic D2 gastrectomy was completed, additional laparoscopic para-aortic lymph node dissection was performed. The right Toldt’s space was separated to exposed the right reproductive vessels and ureter. Then the duodenum, pancreas head and mesentery were mobilized to exposed the inferior vena cava and abdominal aorta. The retroperitoneum was cut at the bifurcation of abdominal aorta and the para-aortic lymph node was dissected caudal to cranial. The inferior mesenteric artery was exposed with 16-b2 lymph node dissection. The renal vein was exposed with 16-b1 lymph node dissection. The lymphatic tissue and fatty tissue posterior to pancreas was dissection. Then the celiac trunk and esophageal hiatus were exposed with 16-a2 and a1 lymph node dissection.

V187

Re-Laparoscopy in Low Insertion Remnant Cystic Duct Calculi with Type 1 Mirrizzi Syndrome

Manoj K Choudhury, MS, FMAS, Hrishikesh Deka, MS; Nemcare Superspeciality Hospital

Objective: Re-laparoscopy in gall bladder or cystic duct remnant with calculous disease is a technically difficult approach. It carries increased conversion and biliary complications. But the morbidity is significantly reduced if performed successfully. Our objective is to reduce the morbidity of the patient.

Method & procedure: A lady aged 37 years was presented with recurrent acute upper abdominal pain radiating to the back since last two months. She had undergone laparoscopic cholecystectomy in 2010. Ultrasound examination showed cystic duct calculi. MRCP report showed multiple calculi in GB Stump with intra hepatic biliary dilatation. CBD diameter showed 10 mm. After complete work up and satisfactory counseling she was prepared for re-laparoscopy.

Under general anesthesia CO2 insufflations was done and ports were introduced as done in conventional laparoscopic cholecystectomy. Adhesiolysis was done and porta was exposed. Cystic duct Stump with the calculi was found to be buried alongside the CHD and was carefully dissected out. Stump showed low insertion into the postero- lateral wall of CBD. A calculus was found impacted at cystic duct-CBD junction. Calculus was niched out and the remnant cystic duct stump was excised. The stump was transfixed. Normal saline irrigation was given, drainage applied and ports were closed.

Results: Post operative period was uneventful. Drainage was removed next day and the patient was discharged with advice.

Conclusion: Re-laparoscopy in cystic duct remnant is a technically difficult procedure. Advances in technology and technical skill are necessary to perform safe surgery

V189

Laparoscopic Repair of Recurrent Type II Hiatal Hernia in Patient with Prior Whipple

Courtney L Devin, MD, Andrew M Brown, MD, Jessica A Latona, MD, Michael J Pucci, Francesco Palazzo; Thomas Jefferson University

The video shows the steps undertaken for a laparoscopic repair of recurrent type II hiatal hernia in a patient with a prior Whipple procedure. Redo laparoscopic paraesophageal hernia repairs can be performed safely in experienced centers.

V190

Laparoscopic Cholecystectomy and CBD Exploration using Choledocotomy and Primary Closure following failed ERCP: A novel 3-port Technique

Daniel Gomez, MD, FACS1, Luis F Cabrera, General Surgeon 2, Andres Mendoza, General Surgeon2, Ricardo Villarreal2, Mauricio Pedraza2, Jean Pulido2, Eric E Vinck2, Sebastian Sanchez2; 1CPO, 2Bosque University

Introduction: Laparoscopy has many known advantages, including shorter hospital stay and less risk of surgical site infection, however, when applied to Mirizzi Syndrome, due to the technical challenges, the degree of conversion to open surgery is very high, varying from 11.1 to 80%, as reported in the literature. Therefore, some experts recommend a laparoscopic approach only, for the management of Mirizzi Grade I Syndrome, due to the high risk of bile duct injury and the distortion of the anatomy.

Objectives: Show through a video presentation that the laparoscopic management of grade IV Mirizzi Syndrome is feasible in expert hands, with favorable results for the patient.

Materials: During a laparoscopic cholecystectomy we found a biliary fistula compromising more than a 66% of the common bile duct circumference, compatible with Mirizzi grade IV syndrome, then we proceeded with the resection of the fistula and subsequent reconstruction of the bile duct with a hepaticojejunostomy and Roux en Y, using a simplified technique similar to that described in the laparoscopic simplified gastric bypass by Cardoso and Galvao.

Results: Surgical time of 118.6 minutes, intraoperative bleeding of 15 cc, oral feeding and adequate tolerance POD 1, no reinterventions, no postoperative biliary leak, hospital stay of 5 days, and at 18 months follow up the patient remains asymptomatic.

Conclusions: The laparoscopic management of complex biliary tract disease demands the knowledge and expertise of surgical groups, trained in advanced laparoscopic techniques in order to be feasible and safe as demonstrated in this case.

V191

Laparoscopic anterior resection with side to side Colo-rectal stapled anastomosis

Dhaivat K Vaishnav; Asian Bariatrics

A 47 year old male presented with bleeding per rectum for one month duration. He had history of chronic pancreatitis for 4 year duration. On clonoscopy there was polyploidal growth at 20 cm from anal verge. CECT abdomen showed recto sigmoid wall thickening with intra luminal poly ploidal growth. Patient was taken up for surgery after preoperative evaluation. Position of patient-lithotomy with flat legs. Post position-2 × 5 mm ports on either iliac fossas, 1 × 10 mm post at umbilicus and 2 × 12 mm para umbilical ports at mid clavicular line. Medial to lateral dissection started, IMA root dissected of and clipped doubly and cut. Rectum mobilized with mesorectum 5 cm below growth. Proximal resection margin defined. Proximal and distal colon transected using endo GIA stapler using 60. Total laparoscopic side to side colo rectal anastomosis fashioned using endo GIA stapler. Leak test was negative. No diversion stoma fashioned. Hemostasis achieved. Drain kept in pelvis. On post operative day two oral was started. Patient discharged after passed stool on post operative day three.

V192

Mesenteric approach for laparoscopic pancreatectomy

Masafumi Nakamura, MD, PhD, FACS, Yoshihiro Miyasaka, MD, PhD, Kohei Nakata, MD, PhD, Yasuhisa Mori, MD, PhD, Takao Ohtsuka, MD, PhD; Kyushu University

Background: Laparoscopic pancreatic resection (LPR) is still challenging in the field of minimally invasive surgeries. One of the critical anatomy in LPR is that the pancreas is fixed to the retroperitoneal space. Mobilization of the pancreas along transverse axis is not feasible in laparoscopic surgery because laparoscope does not provide a good field of vision along transverse axis. We here present our method to mobilize pancreas via the window opened in the mesenterium along longitudinal axis.

Methods: “Mesenteric approach for laparoscopic pancreatectomy”: In the LDP, a window was opened in the mesenterium at the border of the mesenterium of small intestine and that of ascending colon. The aorta appeared soon because the tissue around this border is always thin. We continued to expose the aorta to the cranial and reached the left renal vein in front of the aorta. After dissection of the tissue around the left renal vein, a vein of the left adrenal gland appeared. We entered the layer of RAMPS, Radical Antegrade Modular Pancreatosplenectomy, after cutting this vein. In the LPD, a window was opened in the mesenterium close to the duodenum. We entered the layer between pancreas head and IVC through this window. Pancreas head was completely mobilized through this window.

Results: We have performed 278 cases of laparoscopic pancreatectomies and we used mesenteric approach for all cases in LPD and cancers in LDP. In-hospital death was 0.4%.

Conclusions: Mesenteric approach for LDP and LPD is feasible and safe.

V193

Laparoscopic excision of bronchogenic cyst with vascular mapping

Girish D Bakhshi, MS, MRCS, DNB, FCPS, MNAMS, FMAS, FIAGES, Ruchira Bhattacharya, MBBS, Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Amol N Wagh, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Jalbaji P More, MS, Shraddha D Gangawane, MS, Priyanka Saha, MBBS; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Bronchogenic cysts are rare congenital anomalies of ventral foregut. subdiaphragmatic bronchogenic cysts are extremely rare and accounts for 0.03% of all retroperitoneal tumours. They behave like wandering cysts and tend to have feeding vessels nearby vascular pedicles.

This presentation highlights the laparoscopic excision technique and use of indocyanine green fluorescence for proper delineation of the vascularity and enable safe dissection.

V194

Laparoscopic Total Abdominal Colectomy (LTC) As the First Step of Three-Stage Surgical Treatment of Ulcerative Colitis (UC) - A Systematic Approach

Mariane Camargo, MD, Tracy Hull, MD, Scott R Steele, MD, Conor P Delaney, Hermann Kessler, MD, PhD; Cleveland Clinic Foundation

With the patient placed in the modified lithotomy position, a short midline incision was made below the umbilicus, and gradually the abdominal cavity was entered. A 12 mm balloon trocar was implanted as camera trocar, and pneumoperitoneum was established. Three 5 mm trocars were implanted in the left lower, left middle, and right middle abdomen and one 12 mm trocar in the right lower abdomen. Medial to lateral approach was applied for the dissection of the entire colon. The procedure was started in the right colon, progressing towards the transverse, descending and sigmoid colon. Colonic segments were devascularized and then mobilized using a sealing device for safe dissection and hemostasis during the procedure. Left ureter, left gonadal vessels and both hypogastric nerves were carefully preserved and dissected posteriorly. A short lower midline incision was made above the symphysis and mobilized rectum and colon were protruded in front of the abdomen until the ileum showed up and it was transected using the Endostapler and a 60 mm cartridge. The entire small bowel was run down from Treitz towards the ileum to rule out any twisting of the mesentery. Finally, at the premarked spot in the right middle abdomen, the skin was incised circularly and the ileal stump was protruded in front of the abdomen.

The operative time was 205 minutes, estimated blood loss of 20 ml, no need for transfusion, 1900 ml of intravenous fluids were administered. The patient’ stoma started functioning on postoperative day one, and a soft diet was well tolerated. The patient was discharged home on postoperative day two in stable condition. No 30-day postoperative complications occurred.

A laparoscopic total colectomy for ulcerative colitis patients is safe, results in shorter hospital stay and reduction of postoperative infectious complications, and it should be the approach of choice in experiment hands.

V195

Laparoscopic Management of Adult Intussusception

Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Dattaguru R Kulkarni, MS, Mch, Jalbaji P More, MS, Amol N Wagh, MS, FMAS, FIAGES, FAIS, FICS, FBMS, FLCS, Eham A Arora, MS, DNB, Shekhar A Jadhav, MS, FMAS, Amarjeet E Tandur, MS, Nidhisha Sadhwani, MS; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Adult intussusception is very rare entity. It is more frequently due to a pathologic lead point including: polyps, meckels diverticulum or malignant lesions.

Preoperative diagnosis is challenging due to atypical presentation, and usually is established by abdominal CT.

We present a series of 23 patients managed by laparoscopic surgery. Laparoscopic techniques offer an novel approach in management of adult intussusception and is superior to conventional open surgery.

V196

Single-port Laparoscopic Left Hepatectomy

Dandan Hu, Jiancong Chen, Zhongguo Zhou, Minshan Chen, Yaojun Zhang; Sun Yat-Sen University Cancer Center

A 49-year-old male patient was clinically diagnosed with primary liver cancer. His 61 mm intrahepatic lesion was located in Segment IV, and his serum AFP concentration was 3.86 ng/ml, and PIVKA-II level was 101 mAU/ml. After careful preoperative evaluation of this patient, we planned to apply single-port laparoscopic left hepatectomy for him. A simplified single-port device was made at the beginning of the surgical procedure: suture a size 6.5 sterile glove with a 70–70 disposable incision protective sleeve; 4/5 fingers of the glove were respectively connected to a regular trocar; the incision protective sleeve was then placed into the 3 cm paraumbilical vertical incision; pneumoperitoneum was built; and another auxiliary 12 mm trocar was placed 3 cm inferior to the costal margin along the right midclavicular line. The step-by-step surgical procedure was listed below: 1) Dissect the ligamentum teres hepatis and falciform ligament, explore of the size and location of the intrahepatic lesion with intraoperative laparoscopic ultrasound; 2) Resect the gull bladder; 3) Dissect the primary hepatic portal, ligate and cut the left hepatic artery, ligate the left portal vein with silk thread; 4) Dissect the liver parenchyma with ultrasound knife along the ischemic line, special attention should be paid when dealing with the branches of the middle hepatic vein; 5) Use an endo-GIA stapler to ligate and split the left hepatic pedicle and left hepatic vein, and specimen was then removed; 6) Bipolar coagulation forceps was used to control the bleeding of the surgical plane, and a drainage tube was placed in the right subphrenic space, and the specimen was taken out from the abdomen. Total surgical duration was 150 minutes with 300 ml blood loss. No complication was reported and the patient was dismissed from hospital 6 days after the procedure.

V197

Robotic Transanal Removal of Large Rectal Polyp

Joseph Youssef, DO 1, Arthur Berg, DO1, Shirley Xing1, Anna Serur, MD2; 1Hackensack University Medical Center, 2Englewood Hospital and Medical Center

This is a video case presentation of a robotic transanal excision of rectal polyp that is 10 cm deep and > 5 cm in size. The depth and size of the polyp makes this an interesting case due to the maneuverability required to obtain appropriate margins and total excision. An overview of the case is given and the technique at by which the dissection was done is described.

V198

Robot-Assisted Laparoscopic Trans-Abdominal Excision of a Retro-Rectal Mass

Pamela A Rudnick, MD, Ramon A Brown, MD; Keeler Medical Center, Keeler Air Force Base

Introduction: When addressing the surgical treatment of a pre-sacral tumor, resection may take place via either the conventional open approach or the more novel trans-abdominal approach with robot assistance. We present a case of a 56-year-old male who underwent the latter for an incidentally discovered 3 cm retro-rectal mass.

Surgical Technique: Four port sites configured transversely across the abdomen were used to triangulate on the pelvis. After docking of the robot and insertion of the instruments under direct visualization, dissection was carried on to into the pelvis and the rectosigmoid junction identified. The peritoneum was incised along the right lateral aspect of the rectum and the sacral promontory exposed. The pre-sacral space was then entered and dissection continued to the pelvic mass. The mass was circumferentially dissected from the surrounding, liberated from the pelvis, and removed through the 12 mm trocar site. The peritoneal defect was closed via a self-locking absorbable suture.

Results: The patient was successfully treated with robot-assisted trans-abdominal excision of his retro-rectal mass and was discharged home on post-operative day one. This surgical technique proved to be both safe and feasible.

Conclusion: Continued advancement of robot-assisted surgery may show that a trans-abdominal approach to resection of pre-sacral tumors is superior to the perineal approach.

V199

Laparoscopic Robotic-Assisted Conversion from Slipped Nissen to Roux-en-Y Gastric Bypass

Enrique F Elli, MD, FACS, Myrian Vinan-Vega, MD, Tamara Diaz Vico, MD; Mayo Clinic Florida

A 67 years-old female (BMI = 36 kg/m2), with history of laparoscopic Nissen fundoplication, presented with epigastric pain and regurgitation. Preoperative studies were performed. Upper GI showed a recurrence of the hiatal hernia and a slipped Nissen, which was confirmed by the endoscopy.

Patient was selected to undergo a robotic conversion into a Roux-en-Y gastric bypass.

The procedure started with the dissection of the hiatus. There were dense adhesions between the liver, the stomach, and the previous wrap. Using robotic scissors, all these adhesions were carefully removed. Some of the short gastric vessels were divided and, from the left side, the mediastinum was accessed. A bougie was then passed to identified the esophagus and have a clear anatomy. The fundoplication was dissected from the esophagus and, after dissecting the right crus, the mediastinum was accessed through this side too in order to bring the gastroesophageal junction back to the abdomen. A retroesophageal window was created and a Penrose drain was passed around in order to facilitate the dissection.

Once the hiatus was completed dissected, the hiatal hernia was repaired with interrupted 0-Ethibond sutures. Three sutures were needed to complete the hiatal hernia repair. A retrogastric window was created 5 cm below the gastroesophageal junction in order to construct the gastric pouch with an endoGIA purple load. The jejuno-jejunostomy was performed using a side-to-side mechanic anastomosis. The enterotomy was closed with 3-0 PDS suture in a running fashion. The alimentary limb was added up using an antecolic technique, and the gastro-jejunostomy was constructed with running 3-0 PDS sutures.

The operative room time was 4 hours. The postoperative upper GI showed no evidence of leaks. The patient was asymptomatic and she was discharged in the postoperative day 3. No recurrence of the hiatal hernia was evidenced.

V200

Laparoscopic simultaneous united rectopexy and hysteropexy by our modified Ripstein method with single mesh for the both of rectal and uterine prolapse

Tokihito Nishida, PhD; Department of Surgery, Kasai City Hospital, Hyogo, Japan

Aim: Usually, the repair of rectal or uterine prolapse was undergone by separate method each other in respective department of surgery or gynecology. We devised a new technique of laparoscopic simultaneous united rectopexy and hysteropexy by our modified Ripstein method with single mesh for the both of rectal and uterine prolapse. We experienced two cases of them and operated by our new technique.

Methods: Case1 was 82-year-old female, who had treated with Myers ring for uterine prolapse from 56-year-old, came to our department with complete rectal prolapse of 5 cm length. Case2 was 74-year-old female, who presented rectal prolapse one month ago, came to our department and showed both of rectal (4 cm length) and uterine (4 cm length) prolapse. Operative procedures were as follows; under general anesthesia of lithotomy position, under laparoscope, we exfoliated the rectum of RS, Ra and dorsal Rb from sacrum with TME technique, modified Ripsetin method, cut single BARD mesh into a T-shape (transverse 12-15 cm, vertical 7.5-8 cm, short side 5 cm), attached the mesh to the pulled-up rectum, fixed the mesh to ventral rectum with Endo Universal Stapler, fixed the mesh to sacrum with AbsorbaTack ± Endo Universal Stapler, and at last fixed uterine neck to the internal angle of mesh and uterine body to the top of mesh with 3-0 nylon thread. In this way, laparoscopic simultaneous united rectopexy and hysteropeccy was performed.

Results: In each case, operative time were 147 and 178 min., blood loss were 3 and 4 grams, there was no morbidity, meals were started on POD1 and patients were discharged on POD7. In case1, prolapse of vaginal anterior wall occurred 4 months after, and only colpocystocele was diagnosed on abdominal CT 6 months after. A pessary ring was inserted at gynecology of our hospital. She has constipation sometimes, no fecal incontinence and no urinary incontinence 6 months after the operation. In case2, she has no recurrence, no constipation, fecal incontinence sometimes and no urinary incontinence 5 months after the operation.

Conclusions: Laparoscopic simultaneous united rectopexy and hysteropexy by our modified Ripstein method with single mesh was effective for the both of rectal and uterine prolapse. We show a video of the procedure.

V201

Laparoscopic Heller Myotomy in a Patient with Situs Inversus of Liver

Syed Abbas, MD; UFlorida - Jacksonville

Achalasia is a rare esophageal motility disorder that has an incidence of 1 in 100,000 Americans. The predominant symptom is dysphagia. Three distinct subtypes are described based on high resolution manometry. A surgical or endoscopic myotomy is the treatment of choice. Situs Inversus of abdominal and thoracic viscera has a reported incidence of 1 in 10,000 live births, but the incidence of isolated situs inversus of the liver is probably unknown. We present a patient with type II achalasia with coexistent situs inversus of the liver.

V202

Laparoscopic anterior and posterior mesh rectopexy combined with levatorplasty for posterior rectocele

Nathalie Deferm, MD, Vicky Dhooghe, MD, Gabriele Bislenghi, MD, André D’hoore, MD, PhD, Albert Wolthuis, MD, PhD; UZ Leuven

Introduction: Laparoscopic ventral mesh rectopexy has been widely used for rectal prolapse. In case of posterior prolapse, this technique could be insufficient. The purpose of this multimedia abstract is to present a technique of combined laparoscopic anterior and posterior rectopexy with levatorplasty for posterior rectocele.

Case Report: We report a case of a 26 year-old male with a history of incomplete defecation. RX-defecography showed a posterior rectocele due to pelvic floor insufficiency. Anterior and posterior rectopexy with levatorplasty was performed by a four port technique. The first step was the dissection of the posterior rectal plane with bilateral dissection up to the pelvic floor where a central gap was observed. Levatorplasty was performed by approximating sutures (Ethibond). Secondly a J-shaped incision was performed over the peritoneum with the development of the anterior plane up to the pelvic floor. Afterwards, the peritoneum was opened over the promontory and 2 marlex meshes were introduced anterior and posterior to the rectum and secured with Vicryl and glue to the mesorectum. Finally, the meshes were fixed to the promontory with endo-tackers avoiding the hypogastric nerves. Operative time was 124 minutes. Postoperative course was uneventful with a hospital stay of 2 days. Possible complications are bleeding, mesh erosion and pelvic pain.

Conclusion: In case of posterior rectocele, laparoscopic anterior and posterior rectopexy combined with a levatorplasty is feasible and offers a complete repair.

V204

Endoscopic Approach to Colorectal Anastomotic Stricture

Mariane Camargo, MD1, Thaís Reif De Paula, MD2, Scott R Steele, MD1, Conor P Delaney, MD, PhD1, Hermann Kessler 1; 1Cleveland Clinic Foundation, 2Columbia University

Anastomotic leakage (AL) is an important complication after colorectal surgery, leading to high rates of morbidity, prolonged hospitalization, and mortality. It often requires further surgery and stoma formation. The aim of this video is to show an option to operative approach of an anastomotic stricture that was developed after an anastomotic leak.

The patient underwent surgery for rectal cancer with a primary anastomosis and no ostomy. On the 6th postoperative day, there was an AL and he was diverted. He subsequently received both adjuvant radiotherapy and chemotherapy. A CT scan and an MRI revealed a presacral mass and complete obliteration of the anastomosis. Ultrasound-guided biopsies were taken from the presacral mass, which did not show any malignancy, but only scar tissue. A Gastrografin enema revealed the rectal stump to be entirely occluded. The patient also had a background history of pulmonary embolism, which had occurred postoperatively and he had been on treatment for about 9 months at that time and then was taken off anticoagulation. He was now very hesitant to undergo a major abdominal and pelvic surgery for resection of the anastomosis and new restoration of the bowel continuity.

Procedure: Simultaneously using a second colonoscope, the afferent loop of the transverse colostomy was scoped towards the proximal side of the anastomotic stricture. The obliterated oral side of the anastomosis was reached after about 65 cm. However, the light of the lower colonoscope was transparent and could be identified through the scar stricture. Using a needle knife and electrosurgery, the scar was now stepwise excised first from proximally then from the distal rectal side until an opening was created, which was big enough to protrude a guidewire from proximally towards distally. With the guidewire placed, further excision of the scar was performed using a needle knife. A lumen of about 2 cm was reached. A guide wire was adapted in position and left in place and sutured towards the skin of the abdomen for further potential dilatations before ostomy closure.

A colonoscopy was performed after 3 weeks and showed a patent anastomosis. The stoma was closed and the patient underwent more dilations in the follow-up. After 5 months, a wide open anastomosis could be seen. The patient reported a relief in symptoms.

This case had success in the nonoperative approach to an anastomotic complication and could reduce the morbidity for this patient. The indication should be considered case by case.

V205

Laparoscopic hepatic cyst fenestration with biliary leak repair

Usah Khrucharoen, Yen-Yi Juo, Andrew Scott, Erik Dutson; UCLA

In this video, we present a patient with progressive polycystic liver disease undergoing laparoscopic hepatic cyst fenestration. The patient had previously undergone 4 prior laparoscopic hepatic cyst fenestration, yet her abdominal pain and distension recurred due to disease progression. The aim of this operation is to reduce the total cystic fluid volume by unroofing all reachable large cysts and draining their cystic fluid. Due to the distorted intrahepatic biliary anatomy, biliary fistula is one of the most common concerns following the procedure. In this video, biliary leak from unroofed hepatic cyst could be observed intraoperatively, requiring primary repair of the opened cyst wall by intracorporeal suturing with monofilament non-absorbable sutures. Postoperative course was uneventful. The patient endorsed improvement in distension symptoms and was able to tolerate oral intake and was discharged on postoperative day 3.

V207

Laparoscopic enucleation of single lesion insulinoma without aid of intra operative ultrasonography

Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS1, Soumya L Chatnalkar, MBBS1, Amol N Wagh, MS, FMAS, FIAGES, FAIS, FICS, FBMS1, Shekhar Jadhav1, Eham L Arora, MS, DNB1, Jai Rathod, MBBS1, Khusboo N Kadakia, MBBS1, Shivang Shukla, MBBS1, Umang D Shandilaya, MBBS 2; 1Grant Government Medical College & Sir JJ Group of Hospitals, Mumbai, India& Sir JJ Group of Hospitals, Mumbai, India, 2Grant Govt. Medical College & Sir J.J. Group of Hospitals, Byculla, Maharashtra, India

Insulinoma is rare functional neuroendocrine tumor. Causing symptoms due to uncontrolled secretion of insulin leading to hypoglycemia.

Surgical management is the curative, with laparoscopic enucleation and distil pancreatectomy.

Laparoscopic enucleation with intraoperative localisation of lesion with ultrasonic probe being standard technique.

This video highlights laparoscopic enucleation technique of single lesion insulinoma with help of other modalities in absence of laparoscopic ultrasonic probe .Technique is based on haptic sensation by laparoscopic instrument palpation.

V208

Per-Oral Endoscopic Myotomy (POEM) of Posterior Wall after Multiple Failed Foregut Operations

Armando Rosales, MD, Tymothy A Woodward, MD, Steven P Bowers, MD; Mayo Clinic Florida

Introduction: Recurrent or persistent symptoms after Heller myotomy occur in approximately 10–20% of patients. Per-Oral Endoscopy Myotomy (POEM) is a possible treatment modality available to avoid a reoperation at the gastroesophageal junction in patients with failed Heller myotomy (HM). POEM can be technically successful in approximately 98% and with 81% clinical response in patients with prior HM.

Methods: Our patient is a 56-yo F with multiple foregut surgeries, she presented to clinic with distal esophageal spasms and heartburn. Preoperative pH manometry was consistent with esophageal stasis. Upper gastrointestinal showed an anterior diverticulum. Patient underwent a POEM of posterior wall.

Results: The procedure was uneventful. Adequate posterior wall circular muscle myotomy was accomplished up to the gastroesophageal junction. Postoperatively, the upper gastrointestinal image studies did not revealed a leak, and showed adequate passage of contrast. Currently, doing well.

Conclusion: In order to avoid a reoperation, POEM of posterior wall is an acceptable and safe procedure

V209

Laparoscopic Morgagni Hernia Repair

Julie G Grossman, MD, Arghavan Salles, MD, PhD; Washington University School of Medicine

Introduction: Morgagni hernias are congenital defects found in the anterior space of the diaphragm. They are the rarest of the congenital diaphragmatic hernias, making up only 3% of all diaphragmatic hernias. It is an especially rare entity among adults and because of this, definitive management strategies have not been well-defined. We present an effective method of laparoscopic repair.

Procedures: Two cases of laparoscopic Morgagni hernia repairs were performed on symptomatic adult patients, who had preoperative complaints of chest and abdominal pain.

Results: Primary closure of Morgagni hernia defects were performed in two different ways, utilizing a trans-fascial mattress repair. The first was anterior-posterior, while the second was closed transversely. Polypropylene mesh was used to reinforce the repair. Tacks were utilized for mesh placement in all areas, except for the posterior edge, which was in proximity to the heart, where fibrin sealant was used. Both patients did well postoperatively and remain free of symptoms.

Conclusion: The laparoscopic approach allows for a short post-operative course, good long-term outcomes, and increased intraoperative visualization with minimal morbidity. We have shown that the use of trans-fascial sutures is technically feasible and allows for secure closure of the defect. Additionally, we have illustrated the use of fibrin sealant for mesh fixation in areas which are inappropriate for tacks, such as in proximity to the heart. In summary, Morgagni hernias are rare among adults but can be treated laparoscopically, while also allowing for primary closure of defects.

V210

Situs Ambiguus, understanding the challenges for Nissen fundoplication

Carlos Chavez De Paz, MD, Juan C Quispe, MD, Maher Musleh, MD, Crystal Alvarez, DO, Aarthy Kannappan, MD, Panisha Kittipha, MSN, Daniel Srikureja, MD, Jeffrey Quigley, DO, Keith Scharf, DO, Esther Wu, MD, Marcos Michelotti, MD; Loma Linda University Health

The patient is a 47-year-old female with the diagnosis of situs ambiguus and a hiatal hernia, associated with Barrett’s esophagus. She was evaluated for symptoms of refractory acid reflux and regurgitation. On the last two years, she underwent multiple esophagogastroduodenoscopies with HALO-90® radiofrequency ablation of the distal third of the esophagus. The patient had and attempted Nissen procedure at another institution, which was aborted due to technical difficulties. She was referred to our institution for higher level of care.

After appropriate workup and review of imaging, the patient underwent a robotic-assisted repair of the hiatal hernia with bio-absorbable mesh and Nissen fundoplication. The surgery was carefully planned and the robot was docked with the ports in a mirror-like way than for a conventional case. The technical challenges of operating with a right sided stomach and a midline liver are described. The hernia was reduced with the mesh placed as well as the fundoplication was done without complications. Her post-operative course was uneventful, she was discharged on a blenderized diet. Eight weeks after surgery she was eating a regular diet, denied any symptoms of reflux and had stopped taking anti-acid medications.

V211

Laparoscopic Roux-en-Y Gastric Bypass After Previous Nissen Fundoplication

Agustin Duro, MD, Patricia Saleg, MD, Virginia M Cano Busnelli, MD, Fernando G Wright, MD, Axel F Beskow, MD, Demetrio Cavadas, MD, PhD; Hospital Italiano de Buenos Aires

Reoperative antireflux surgery after Nissen fundoplication is technically challenging and associated with high recurrence rates, especially in obese patients. In these cases, Roux-en-Y gastric bypass (RYGB) may represent a superior alternative to reoperative fundoplication to simultaneously treat gastroesophageal reflux disease (GERD) and obesity, and prevent further recurrences.

This video shows a 62-year-old woman with a BMI of 35 who consulted for morbid obesity and typical GERD symptoms. She had undergone an open cholecystectomy and a laparoscopic Nissen fundoplication eight years before. She had also history of hypertension and dyslipidemia. A CT scan, esophagram and endoscopy revealed a large sliding hiatal hernia. Operative technique included extensive lysis of adhesions between the left lateral sector of the liver and the stomach, complete wrap take down, partial gastrectomy of the fundus, hiatal hernia repair with a bioabsorbable mesh and RYGB. She had no postoperative complications and was discharged on the second postoperative day. At 3 months, she had lost 42% of her excess body weight and remained asymptomatic for GERD.

Although technically demanding, conversion of a Nissen fundoplication to RYGB seems to be safe and effective to treat recurrent GERD in morbidly obese patients, with better outcomes than redo fundoplication.

V212

Bariatric Surgery in a Patient with Severe Congenital Intestinal Abnormalities

Robert J Conrad, MD, Nicole R Laferriere, MD, Miriam L Brazer, MD, Dylan M Russell, MD, Chan W Park, MD, FACS, Robert B Lim, MD, FACS; Tripler Army Medical Center

Introduction: We present a case in which we performed a laparoscopic sleeve gastrectomy and cholecystectomy, in a patient with intestinal malrotation and a common bile duct anterior to the stomach. The patient is a 51 year old female with class I obesity and metabolic syndrome who presented to our clinic interested in a Roux-En-Y Gastric Bypass (RNYGB), with the caveat that she had congenital anomalies that caused a previous attempt at a RNYGB to be aborted at another facility. She was noted to have malrotation but there was no description of the intraoperative anatomical findings. Preoperative imaging demonstrated intestinal malrotation with the small bowel largely to the right of the abdomen and the large bowel on the left side of the abdomen as well as polysplenia. Also noted is a bilobed liver and an anterior and midline gallbladder with cholelithiasis. Last and most importantly, the portal vein, superior mesenteric vein and common bile duct were anterior to the stomach near the level of the pylorus. Our plan was to offer this patient a RNYGB pending diagnostic laparoscopy and intraoperative real time endoscopy to assess her anatomy. She was also consented for possible Ladd’s Procedure, possible Laparoscopic Sleeve Gastrectomy and Cholecystectomy.

Methods: This is a video case report with intraoperative video narration of a laparoscopic surgery.

Results: In summary, the patient had malrotation with the duodenum extending intraperitoneally to the LUQ but returning retroperitoneally to the RUQ with the common bile duct laying anterior to the stomach. The celiac axis was underdeveloped thus necessitating a laparoscopic sleeve gastrectomy as opposed to a gastric bypass.

Conclusion: The learning point being that, the use of preoperative imaging and intraoperative adjuncts such as diagnostic laparoscopy and endoscopy helped define this unique and complex anatomy, thus allowing for a safe and successful surgical procedure.

V213

Laparoscopic Paraduodenal Hernia Repair

Joe Nigh, BS 1, Benedict Hui, MD2, Guido M Sclabas, MD2, Geoffrey S Chow, MD2; 1University of Oklahoma School of Community Medicine, 2University of Oklahoma Tulsa Department of Surgery

The attached video is a case presentation displaying principles of laparoscopic technique in the repair of a left-sided paraduodenal hernia, a rare cause of small bowel obstruction. In the video and explanation slides, an overview of the concepts related to paraduodenal hernias is presented, and video footage of the laparoscopic repair is shown. The purpose of the video footage is to illustrate the principles of utilizing this technique for this type of hernia repair. The educational aspect that the case presents is one that illustrates a rare cause of small bowel obstruction and the technique by which this condition can be managed.

V214

Robotic Heller Myotomy with Partial Fundoplication Using Cold Myotomy Technique

Lindsay Nelson, DO, Alexander Marinica, DO, Fazaldin Moghul, DO, Abubaker Ali; Detroit Medical Center/Sinai-Grace Hospital

Introduction: Heller myotomies are a standard procedure for achalasia. Minimally invasive surgery has become a frequently utilized technique, with an increasing use of robotic procedures. Cold myotomies using blunt dissection are frequently used with laparoscopic surgery but not documented in use for robotic myotomies.

Case Presentation: 60 year old female with symptomatic refractory achalaisa undergoes a robotic heller myotomy after extensive workup and several therapeutic EGDs without relief. A robotic heller myotomy utilizing cold myotomy with Dor fundoplication is performed as described in the included video abstract. She reports successful improvement in symptoms post-operatively without any adverse events and no leak noted post-operatively.

Conclusion: Cold myotomy technique is an underutilized technique that can be performed to achieve effective myotomy for achalaisa during robotic surgery. While limited tactile feedback exists in robotic surgery compared to laparoscopic surgery, the enhance 3D visualization and magnification allow for successful myotomy while avoid thermal injury and therefore delayed leaks secondary to mucosal injury.

V215

Postoperative Pain after Laparoscopic Flank Hernia Repair Requiring Suture Removal

Philip E George, Loic Tchokouani, Brian Jacob; Icahn School of Medicine at Mount Sinai

We present a case of a 56 year old female with a history of diabetes and hypertension who is status post a sleeve gastrectomy who presented to our clinic with both a Grynfelt hernia and umbilical/incisional hernia bulge. The Grynfelt hernia was repaired laparoscopically preperitoneally with a primary closure and overlying progrip mesh. The patient had severe postoperative pain that was neuropathic in nature and after conservative management and high suspicion that there was nerve entrapment by the primary repair we elected to take the patient to the operating room for exploration. We explored the patient laparoscopically and removed the primary closure suture and found the L1 nerve root which was likely caught in the repair. We left the progrip as a bridging mesh. The patient had a great decrease in the amount of pain she was feeling post operatively. One should always be suspicious of nerve entrapment in a patient with severe postoperative pain and dermatome distribution which gets worse after conservative measures.

V216

Single-port thoracic-assisted laparoscopic proximal esophagogastrectomy for Siewert type 2 adenocarcinoma of esophagogastric junction

Wei Wang; Guangdong Provincial Hospital of Chinese Medicine

The first 12-mm trocar was inserted at the level of the umbilicus for the laparoscope. Then two trocars were inserted on the left side for the operating surgeon and two trocars were placed on the right side for the assistant surgeon. After completely abdominal procedure with No.1, 2, 3, 4, 7, 8a, 9, 11 and 12 a lymph nodes dissection, the left diaphragm was incised 5 to 7 cm, followed by a transthoracic assisted port was inserted into the thoracic cavity through the left axillary frontline at the sixth to eighth intercostal spaces. Then lower mediastinal lymphadenectomy and transection of the lower esophagus were completed with the transthoracic supplementary port. An intrathoracic overlap gastroesophagostomy was performed by using the transthoracic assisted port, which was finally used for thoracic drainage.

V217

Laparoscopic Take-down of Dor Plication with redo of Heller Myotomy

Maria C Fonseca, MD, Cristian A Milla Matute, MD, Joel S Frieder, MD, David Romero Funes, MD, Armando Rosales, MD, Samuel Szomstein, MD, FACS, FASMBS, Emanuele Lo Menzo, MDPhD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Clevelan Clinic Florida

Recurrent achalasia occurs in 10–20% of the cases after surgical myotomy. Therapeutic options entail endoscopic dilatation, Per-oral esophagomyotomy or redo surgical myotomy. We present a case of a 65-year-old male with history of laparoscopic Heller Myotomy and Dor Fundoplication, he is admitted with severe dysphagia and diagnosis of recurrent achalasia is made. Following assessment, he undergoes takedown of fundoplication in addition to a redo of the Heller myotomy. He had an upper GI that showed no leak, however on Post-operative day 7 he had signs of a leak, which was managed non-operatively with full resolution.

V218

Laparoscopic surgery for mechanical small bowel obstruction due to appendicitis

Andrew Mueller, MD 1, Carl Tadaki, MD2; 1University of Hawaii, 2Straub Medical Center

A 53 year old male with no prior history of abdominal surgery presented to the emergency department with a two day history of abdominal pain, nausea and vomiting, and absent flatus and bowel movements. During the initial physical exam the patient was found to have right lower quadrant abdominal pain. Laboratory workup revealed a leukocytosis to 13,600. The patient underwent abdominal two-view X-ray which was suggestive of small bowel obstruction. The patient then underwent CT scan of the abdomen and pelvis, which demonstrated small bowel obstruction with a closed loop and or internal hernia. CT scan also showed wall thickening and small amount of free fluid. The appendix was not seen on CT scan. The patient was consented for exploratory laparoscopy. Intraoperatively the patient was found to have the appendix wrapped around the distal ileum causing a mechanical obstruction. This was freed and an appendectomy was performed. The patient was discharged in good health and tolerating a regular diet on post operative day one.

V219

Laparoscopic Paraesophageal Hernia Repair, Toupet Fundoplication, Cholecystectomy, and Common Bile Duct Exploration in a Patient with Symptomatic Choledocholithiasis

Ryan J Campagna, MD, Amy L Holmstrom, MD, Ezra N Teitelbaum, MD, MEd; Northwestern University Feinberg School of Medicine

We present the case of an 82-year-old female who presented with symptomatic choledocholithiasis. A large type III paraesophageal hernia was discovered during an attempted endoscopic retrograde cholangiopancreatography, which was ultimately unsuccessful due to the hernia. Further questioning revealed a long-standing history of early satiety, heartburn, and regurgitation. She was subsequently taken to the operating room for paraesophageal hernia repair and definitive management of her choledocholithiasis.

V220

The Modified Trans-gastric Endoscopic Rendezvous Technique: Removal of a Non-adjustable Gastric Band

Connal Robertson-More, MD1, Kieran Purich, MD 2, Jerry T Dang, MD2, Aliyah Kanji, MD2, Shahzeer Karmali, MD, MPH2; 1University Hospitals Coventry and Warwickshire NHS Trust, 2University of Alberta

Background: The non-adjustable gastric band was developed by Marcel Molina in 1980 for the treatment of severe obesity. Although demonstrating short term success, this gastric segmentation procedure has generally been abandoned due to complications of gastric stenosis and erosion.

Case: We present a 51 year-old female who had a non-adjustable gastric band placed for severe obesity in 1998. She presented to our clinic with symptoms of proximal gastric outlet obstruction. Further, she was noted to have a low body mass index and malnutrition. Standard preoperative investigations were completed, ultimately showing an eroded non-adjustable gastric band located 2 cm distal to the gastroesophageal junction (GEJ). Following nutritional optimization, the decision was made to remove the band through a modified hybrid technique to relieve her food intolerance and improve her nutritional status.

Technique: A myriad of laparoscopic, endoscopic and hybrid techniques have been described for the removal of eroded gastric bands. Here we describe a modification of an existing hybrid technique which takes advantage of laparoscopic trans-gastric techniques to provide excellent visualization high near the GEJ, endoscopic band removal to minimize the risk of surgical site infection and remains minimally invasive. The use of the laparoscope for visualization within the stomach reduces the technical skill of the procedure compared to the original, making the technique accessible to minimally-invasive surgeons without specialized equipment or specialty trained assistants.

V221

Robotic Transanal Excision of Early Rectal Neoplasm

Jarvis W Walters, DO, Ada Graham, MD, Vincent Obias, MD, FACS, FASCRS; George Washington University Medical Center

The tortuous anatomy of the rectum and distal colon presents challenges in transanal surgery. This video depicts a transanal excision of an early rectal neoplasm using a flexible endoluminal robotic surgical system.

V222

Laparoscopic excision of retro pancreatic retro portal schwannoma

Dhaivat K Vaishnav; Asian Bariatrics

Retropancreatic benign tumors like schwannoma are rare. Minimally invasive excision of this kind of tumor is less preferred. Case report: A 32 year old male presented with epigastric pain radiating to back associated with post prandial abdominal fullness of 1 year duration. Ultrasound abdomen as well as CECT abdomen revealed well defined hypoechoic 3 × 2.8 × 1.8 cm size lesion situated at retro pancreatic region, posterior to main portal vein in aorto-caval groove. EUS guided FNAB reported spindle cell neoplasm. IHC positive for sox-10, S 100 and alpha inhibin confirmed schwannoma. Laparoscopic excision of Schwannoma was done. Post-operative period was uneventful. Conclusion: Laparoscopic excision is feasible in the treatment of retroperitoneal schwannoma. However, advanced laparoscopic skills, meticulous preoperative planning and intraoperative execution are necessary for a successful outcome.

V223

Robotic Heller Myotomy with Dor or Toupet Fundoplication

Sarah Samreen, MD, Crystal M Krause, PhD, Dmitry Oleynikov, MD; University of Nebraska Medical Center

This is a presentation of a robotic Heller Myotomy, showing both a partial anterior (Dor) and a posterior (Toupet) fundoplication. The first case is a 44 year old female who presents with dysphagia and regurgitation. Manometry shows evidence of type I achalasia, and the esophagram presents typical achalasia profile of a bird’s beak appearance. The patient elected to proceed with treatment of a Heller myotomy with a Dor (180° partial anterior) fundoplication. The Myotomy begins by opening the phrenoesophageal ligament and standard mediastinal dissection is performed to mobilize the esophagus. The esophageal fat pad is split, the GE junction and Vagus nerve are identified, and the Vagus nerve is elevated. A lighted 56 Fr Bougie is used to facilitate the robotic dissection. The Myotomy is performed using blunt dissection and hook cautery. The lighted Bougie facilitates identification of the both longitudinal and circular muscle layers as well as the esophageal mucosa. The robot facilitates this due to motion scaling. Once the Myotomy is completed, the Dor fundoplication is started. A permanent O suture is used to secure the angle of His and the fundus to the abdominal wall. The second and third stitches secure the stomach to the cut edge of the myotomy. The Dor is closed with a contralateral stitch to the cut edge of the myotomy to ensure the integrity of the myotomy under the anterior fundoplication of the stomach.

The second case is a 36 year old female who presents with aspiration pneumonia. Patient workup showed a dilated, sigmoid esophagus and manometry consistent with achalasia. The patient elected to proceed with a Heller myotomy and Toupet (270° partial posterior) fundoplication for treatment. Extensive mediastinal dissection is performed for esophageal lengthening and reduction of the hiatal hernia. A Penrose drain is placed around the esophagus and the liver is retracted and proceed with circumferential mobilization of the esophagus away from the hiatus and then extensive mediastinal dissection. Once adequate esophageal mobilization is obtained, the myotomy is performed. The Toupet fundoplication is formed by the placement of permanent sutures at 9:00 and 3:00 positions respective to the esophagus. The Penrose drain is removed, the esophagus is pulled down and secured with stitches to the right and left crura and the cut edge of the myotomy.

V224

Laparosopic Resection of Candy Cane after Roux-En-Y Gastric Bypass

Michelle Estrada, MD, Theophilus Pham, MBA, Adel Alhaj Saleh, MD, MRCS, Amir Aryaie, MD, FACS; Texas Tech University Health Sciences Center

Case Background
  • 49-year-old female with 1-year history of worsening epigastricpain

  • Pain characterized as constant, dull and squeezing, worsened by oral intake, especially of meat and leafy vegetables

  • Associated nausea, vomiting, choking that is worse at night

Medical and Surgical History
  • GERD

  • Cholecystectomy

  • Hysterectomy for fibroids

  • Gastric bypass in 2008

EGD findings
  • 8 cm candy cane (afferent blind limb) at the gastrojejunal anastomosis

Upper GI series findings
  • No extravasation at the gastrojejunostomy site

CT abdomen/pelvis
  • Mild dilatation of the proximal bowel extending to the anastomosis

Laparoscopic revision of Roux-en-Y gastric bypass with resection of afferent blind limb (Candy cane syndrome)
  • 10 cm of Candy cane removed

Post-operative Course
  • Discharged on post-operative day 1

  • 2-week clinic follow up – no nausea/vomiting/food intolerance

V225

Retroperitoneal Tumor Surgical Treatment by Minimally Invasive Approach

Aurelio Francisco Aranzana Gomez, Jara Hernandez Gutierrez, Beatriz Muñoz Jimenez, Juan S Malo Corral; CH Toledo

Introduction: Retroperitoneal primary tumors comprise a great variety of neoplasm with different histological typologies, with insidious clinical symptoms and little specificity in most cases. Its diagnosis is established through imaging tests and anatomopathological study is needed so complete surgical resection is the treatment of choice.

The aim of the video is to demonstrate the safety and efficacy of the minimally invasive approach in patients with retroperitoneal lesions. A clinical case of RETROPERITONEAL TUMOR OF UNCERTAIN ORIGIN is presented.

Methods and Procedures: Clinical case: A 66-year-old female patient who, in the course of an abdominal pain at the right iliac fossa suspected of possible acute appendicitis, is diagnosed with a right retroperitoneal tumor of approximately 3 cm, compatible with PRIMARY TUMOR NEUROGENIC ORIGIN on a CT that was performed. Radiographic imaging is a key component of the evaluation of a patient with a retroperitoneal mass, a CT scan is necessary to evaluate the primary site as well as to rule out metastatic disease. After complete biochemical study, non-functioning tumor is determined. The study is completed with MRI where the lesion is located below the right kidney, in front of the right psoas muscle and lateral to the inferior vena cava, and without contact with these structures. The tumor shows a homogeneous signal, being hypointense in T1 and slightly hyperintense in T2. It is in intimate contact with the ovarian vein. The complementary tests and iconography of interest of the case are exposed. Surgical intervention is proposed with a laparoscopic approach to remove the tumor.

Results: Full minimally invasive approach in left lateral decubitus position: 4 trocars - lateral laparoscopic transabdominal approach. Laparoscopic liberation of the right colon, Kocher maneuver until the inferior vena cava is visualized, identification of a tumor of approximately 5 cm in the right infrarenal region, lateral to the right ureter, which includes the gonadal vessels. Resection of the tumor in block with margins previous dissection and clipping of the proximal and distal gonadal vessels with Ligasure®. Appendectomy with endoGIA. The patient presented a successful postoperative recovery, being discharged 24 hours after the intervention. Definitive result of the specimen: Leiomyosarcoma, grade 2 of the FNCLCC with negative margin.

Conclusion(s): The laparoscopic approach is a safe and effective technique in the approximation of retroperitoneal tumors, a radical oncological criterion is always needed with correct margins of resection especially in those of uncertain etiology.

V226

Laparoendoscopic Transgastric Resection of 2 masses of 8.5 cm

Ann D Smith, MD, MPH, Jaroslav Zivny, MD, Richard A Perugini, MD; University of Massachusetts

Gastrointestinal stromal tumors (GISTs) are rare and the only opportunity for cure is total surgical resection with gross negative margins. National Comprehensive Cancer Network (NCCN) guidelines from 2010 recommend laparoscopic resection for tumors up to 5 cm but recommend open surgery for tumors of 5 cm or greater. However, multiple studies have now shown that laparoscopic or laparoendoscopic surgical resection of these tumors is feasible and gives a comparable oncologic resection as long the tumor capsule is not violated and there is a way to remove the larger masses through a laparoscopic incision. Two patients presented to us with a similar picture: severe anemia and gastric outlet obstruction. Workup revealed they both had 8.5 cm submucosal gastric masses. Masses of this size have the potential to be malignant GISTs. Pre-operative workup showed no evidence of metastatic disease and so resection was recommended for both which we performed laparoendoscopically using the transgastric technique. One mass returned as a low risk GIST and the other was a benign lipoma.

V227

Jejunojejunostomy Intussusception after Laparoscopic Roux-en-Y Gastric Bypass

Andrew M Martin, MD, Brandon M Smith, MD, John G Zografakis, MD; Summa Health System/NEOMED

This video presentation demonstrates the work up, diagnosis, and treatment of a patient with history of Laparoscopic Roux-En-Y gastric bypass who presents with a retrograde jejunal intussusception of the common channel. This particular patient had LRYGB with jejunojejunal anastomosis created using a triple staple technique. As opposed to the double staple technique, the triple staple technique results in a wider lumen and thus lower rates of stricture complications. However, the wider opening does place patients at higher risk of intussusception. While intussusception following LRYGB is a relatively common imaging finding, it is rarely clinically significant. Therefore, clinically significant JJ intussusception is an infrequent diagnosis, yet common enough that physicians may be required to manage this complication during their career and thus should be considered as a differential diagnosis for gastric bypass patients presenting with pain and obstructive symptoms. Definitive management includes operative intervention for reduction of the intussusceptum and assessment of bowel viability. This presentation describes the work up from the emergency room, key diagnostic steps, a video of surgical intussusceptum reduction, and surgical steps taken to limit intussusception recurrence. Overall, this video presentation serves as a diagnosis review and management demonstration to prepare physicians for management of retrograde jejunal intussusception following Laparoscopic Roux-En-Y gastric bypass.

V228

A rare cause of post-operative small bowel obstruction following laparoscopic Roux-En-Y Gastric Bypass surgery

Alph Emmanuel, MD, S. Julie-Ann Lloyd, MD, PhD, Bestoun H Ahmed, MD, FACS, FASMBS; University of Pittsburgh Medical Center, PA

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass surgery is an uncommon complication with reported incidence of 1.5 to 5%. The most common causes are internal hernia, roux limb stricture and adhesions causing 89% of cases. In our patient, the cause of the bowel obstruction was rare and unusual.

Our patient is a 33 year old female who underwent robotic assisted laparoscopic antecolic, antegastric Roux-en-Y gastric bypass. The gastrojejunostomy and jejunojejunostomy were created using a linear stapler with the enterotomy closed using barbed suture. Both mesenteric defects were closed. Patient presented 3 weeks after surgery with nausea, vomiting and abdominal pain. CT scan showed, moderately dilated excluded stomach and BP limb with dilated loops of small bowel adjacent to the JJ anastomosis, there was a band like narrowing suggestive of obstruction. No internal hernia was seen.

Patient was taken to the operating room for laparoscopic exploration. The excluded stomach and BP limb were dilated. The JJ anastomosis was patent with a suture tail extending from the anastomosis to an adjacent loop of small bowel. There was a separate loop of small bowel that was caught under this suture tail causing acute narrowing of the lumen. The suture tail was cut with immediate decompression of the dilated proximal bowel. Bowel resection was not required. There was no internal hernia.

There are few reports of the free end of barbed suture causing a small bowel obstruction. Most of the reports in published literature are in colorectal and gynecological surgery. There are a few reports of similar incidents during closure of the peritoneum in trans-abdominal pre-peritoneal inguinal hernia surgery. There was only one published paper about a similar complication after laparoscopic Roux-en-Y gastric bypass surgery.

Barbed suture is commonly used in complex laparoscopic surgery because it decreases operative time without increase in complications. However, leaving a suture tail can lead to small bowel obstructions. We recommend taking a few extra bites in the tissue after closing the enterotomy to allow the suture tail to be buried. The suture then cut flush with the bowel wall without placing the knot. We have not had any similar complications after introducing this technique in our practice.

V229

Treatment of Refractory GERD: Conversion of Sleeve Gastrectomy and Dor Fundoplication to Gastric Bypass

Crystal Alvarez, DO, Maher Musleh, MD, FACS, Juan Carlos Quispe, MD, Esther Wu, MD, Panicha Kittipha, MSN, RN, Daniel Srikureja, MD, Jeffrey Quigley, DO, Marcos Michelotti, MD, FACS, Keith Scharf, DO, FACS, FASMBS, Aarthy Kannappan, MD; Loma Linda University Medical Center

Our patient is a 50 year old female with a complicated bariatric surgery history who presented to our clinic with persistent GERD symptoms. She had undergone placement of a lap band in 2002 resulting in 100 pound weight loss. A few years later the band slipped and was revised. In 2010, it slipped a second time and was removed. She gained 160 pounds thereafter and subsequently underwent a lap sleeve gastrectomy in 2012. At this time she began to have GERD symptoms. Imaging showed a hiatal hernia, and she was taken to the OR in 2014 for a robotic hiatal hernia repair with mesh. During this operation, excess fundus was noted, and it was used as a Dor fundoplication. She had improvement in GERD symptoms for a few months, but they shortly returned. A few years later she returned for followup and further workup. She was found to have a normal DeMeester score on pH probe testing and EGD showed no evidence of a recurrent hiatal hernia. However, the Dor did not appear to be intact. She continued to have classic GERD symptoms that were affecting her quality of life. She was therefore offered revisional bariatric surgery with conversion to a gastric bypass. The video presented demonstrates the difficult anatomy associated with multiple foregut procedures. Postoperatively, the patient developed a mild gastrojejunal anastomotic stricture around six weeks. This was balloon dilated and she did well afterwards. At her 3 month visit, she was tolerating a regular bariatric diet, lost approximately twenty pounds, and endorsed complete resolution of her GERD symptoms.

V230

Laparoscopic treatment of choledochal cyst with stapled hepaticojejunostomy

Sarfaraz Baig, MS, FRCS; Belle Vue Clinic

Laparoscopic treatment of choledochal cyst is technically challenging. Leak stays the major cause of morbidity.

With time, we have changed our technique of hepaticojejunostomy to include the use of staplers. With this technique, we are able to reduce the tension on the anastomosis as well as have makes the anastomosis easier technically.

At first, a seromuscular layer is taken posteriorly between the posterior common hepatic duct and jejunum. The anastomosis is done with 3-0 PDS as a continuous layer posteriorly taking the staple line. The anterior layer is done with interrupted PDS sutures.

V231

Laparoscopic Morgagni Hernia Repair

Robin B Osofsky, MD, Cyril Kamya, MD, Louis Melendez, Rodrigo Rodriguez, MD, Edward Auyang, MD; University of New Mexico, Department of Surgery

Morgagni-Larrey Hernia is an anteromedial type of congenital diaphragmatic hernia (CDH). They were first described by Morgagni in 1760 and later characterized by Larrey in 1829. It is the least common type of CDH and has a left side predominance (80%). Most are asymptomatic and do not present until adulthood. Repair can be performed via a thorascopic or laparoscopic approach as primary or with mesh. The following is a case report video abstract demonstrating a laparoscopic morgagni hernia repair.

The patient is a 43-year-old female with history of chronic, dull, non-radiating upper abdominal pain with associated constipation, nausea, and emesis. She had a past medical history significant for pancreatitis, bipolar disorder, tobacco use, previous methamphetamine and opiate abuse for which she was on Suboxone. Preoperative CT demonstrated an anteromedial diaphragmatic hernia containing transverse colon and omentum. After preoperative evaluation and clearance patient was scheduled for an elective laparoscopic diaphragmatic hernia repair.

Patient was placed in the supine, split leg, and arms tucked position. Veress entry was employed for access. Hernia was successfully reduced and repair primarily with braided polyester suture. Operative time was 195 minutes EBL was 300 cc. Specimens included omentum and hernia sac.

Postoperatively patient was started on a regular diet. Acute pain was consulted on postoperative day one as patient had history of opiate abuse and current suboxone use. Patient was subsequently transitioned to PO pain medications and discharge home on postoperative day 3. On patient’s one month postoperative visit patient had resolved postoperative pain and resolution of preoperative symptoms of nausea, emesis, and constipation.

V232

Laparoscopic Reversal of Roux-en-Y Gastric Bypass: Roux to Remnant Neo-Gastrojejunostomy

Maria C Fonseca, MD, Coney Bae, MD, Camila Ortiz-Gomez, MD, Joel S Frieder, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

A 52-year-old active smoker with a history of Roux-en-Y gastric bypass (RYGB) 15 years prior presents with recalcitrant diarrhea, weight loss and malnutrition. To ameliorate his dumping syndrome, we performed a laparoscopic reversal of RYGB. After careful lysis of adhesion, a retrocolic, retrogastric RYGB anatomy with 250 cm biliopancreatic and 75 cm roux limb was found. The distal end of the Roux limb was divided and brought to the remnant stomach to create a side-to-side neo-gastrojejunostomy in an antecolic fashion. Post-operatively he had an episode of melena but remained hemodynamically stable with normal hemoglobin. Upper GI on post-operative day (POD) one demonstrated no evidence of leak. The patient tolerated clears and was discharged home. On POD 7, he presented to the emergency room with pneumoperitoneum. He was emergently taken to the operating room for an exploratory laparotomy where an intact anastomosis and a distant perforation in the alimentary limb were found. The abdomen was washed out, and the perforation was repaired primarily. A subsequent upper GI revealed the intact repair, and the patient was eventually discharged with resolution of diarrhea. Intractable dumping syndrome can be ameliorated by reversal of RYGB via neo-gastrojejunostomy. In re-operative patients with altered anatomy and smoking history, smoking cessation, nutritional optimization and careful surgical conduct can help reduce post-operative complications.

V233

Percutaneous Endoscopic Gastrojejunostomy Tube Placement: A Technique Using a Tapered Dilator within a Peel-away Sheath

Jaclyn Clark, MD, Lindsay O’meara, CRNP, Jose J Diaz, MD; University of Maryland

In patients with gastric dysfunction who require nutritional support, jejunal feeding is a safe method for providing enteral nutrition. There are several approaches to place gastrojejunostomy (GJ) tubes, including percutaneous, open, radiologically-guided, endoscopic and various combinations of the above. It can often be difficult to thread the GJ tube into the pylorus, so we present a percutaneous, endoscopic GJ tube placement technique using a tapered dilator within a tear-away sheath. We combine elements from a percutaneous GJ kit as well as a percutaneous tracheostomy kit. We perform upper endoscopy and use safe passage technique to determine candidacy for percutaneous approach. We then fashion a tear-away sheath placed over a tapered tracheal dilator. We place three transabdominal fasteners into the stomach under direct visualization. An incision is made, the angiocatheter inserted into the stomach and a guide wire advanced. The tract is then serially dilated using a tracheal dilators. The dilator-sheath combination is advanced over the guidewire through the stomach into the duodenum. The dilator is removed leaving the sheath in place. The GJ tube is then inserted through the sheath and placement confirmed using fluoroscopy. The tear-away sheath is then removed and the tube secured. This method allows for efficient and facile access to the pylorus.

V234

Laparoscopic plication for stomal prolapse

Richard A Perugini, MD, Nicole Cherng, MD, Justin Maykel, MD; UMass Memorial Health Care

Stomal prolapse is occurs in up to 26% of patients. It can result in pain, obstruction, ulceration, or poorly fitting appliances. Procedures involving resection are most commonly described. However, these procedures remove healthy intestine, and have a high recurrence rate. We present a laparoscopic modification of a plication technique first reported in 1955 by Lichtenstein and Herzikoff.

Our patient is a 54 year old woman with an end ileostomy following total proctocolectomy for Crohn’s disease. She subsequently underwent emergent laparotomy for incarcerated parastomal hernia requiring small bowel resection with revision of ileostomy. Since then, she has undergone multiple local revisions of her stoma for recurrent prolapse, as well as repair of midline incisional hernia. She continued to have issues with stomal prolapse.

We approached this case laparoscopically. The abdomen was accessed with a Veress needle. Minimal adhesiolysis was required. The ileostomy was identified along with some element of a parastomal hernia. We could visualize incorporated mesh from prior keyhole parastomal hernia repair. We used a 2-0 PDS V-Loc suture to decrease the fascial opening of the stoma, incorporating the mesh when able.

Next, we identified the terminal ileum leading to the stoma. This appeared somewhat edematous. We proceeded to construct a “lazy-S” configuration in the terminal ileum using interrupted 2-0 silk seromuscular sutures between bowel loops. The limbs of the “lazy S” were approximately 15 cm in length. We took care to avoid any acute angulations of the bowel. The terminal ileum was anchored in place by the mass of ileum involved in the plication.

Finally, we sutured the terminal ileum up to the peritoneum with interrupted 2-0 silk sutures so that it tracked laterally.

The patient was discharged on postoperative day #1. She was seen in follow up at postoperative day 9 and was doing well.

Stomal prolapse is a common complication. Plication of the distal intestine and concurrent repair of the parastomal hernia is technically feasible via the laparoscopic approach.

V235

Laparoscopic Assisted Excision of Gastroesophageal Inflammatory Fibrotic Polyp

Linda I Yala, MD 1, Rami Lutfi, MD, FACS, FASMBS2, Lindsey Klingbeil, MD2; 1UIC-MGH General Surgery Residency, 2Mercy Hospital, Chicago, IL

Introduction: Gastric polyps include a wide spectrum of lesions with different histology, neoplastic potential, and management. 6% of upper gastrointestinal endoscopies will reveal a lesion. Typically, they are asymptomatic but their presence will warrant biopsy, guiding the next steps of management. Occasionally, adjuncts may provide only a partial picture of the diagnosis and therefore decisions in management must be made intraoperatively.

Methods: We presented a 74-year-old male with multiple co-morbidities who presented after anemia and melanotic stools. An upper gastrointestinal endoscopy on prior admission only showed diffuse gastritis. Now, EGD showed a large, pedunculated polypoid lesion near the squamocolumnar junction. Biopsies were nonspecific. CT scan confirmed an isolated lesion with some gastrohepatic lymph node enlargement. Concern was for gastrointestinal stromal tumor or leiomyoma and the decision was made to remove it laparoscopically due to the location at the gastroesophageal junction, size, and description of a narrow base.

In the operating room, a hiatal hernia was noted and an intraoperative EGD confirmed vicinity of the mass relative to our planned dissection. We then proceeded using the same technique as we utilize for a hiatal hernia repair, identifying and preserving a replaced hepatic artery in the process. A gastrotomy was made, the mass was delivered from the stomach, and it was clear that what was described as a pedunculated lesion was actually wide based and firm, making us more concerned for malignancy. After partial resection and assessment in pathology, it was confirmed as a benign inflammatory fibroid polyp which was then resected in its entirety. We ensured the integrity of the posterior gastric wall and esophagus, closed the gastrotomy, and repaired the hiatal hernia repair. A leak test was negative. The patient’s post operative course was uneventful.

Conclusion: Vanek’s tumor or inflammatory fibroid polyp (IFP) is a rare submucosal, mesenchymal tumor of the digestive tract. It accounts for about 0.1% of all gastric polyps and is most commonly localized to the gastric antrum. Depending on their size and location, IFPs can be associated with nonspecific symptoms. Endoscopic biopsies are often unhelpful and right diagnosis can be reached only with resection. Histopathological examination reveals the presence of spindle cells with eosinophilic infiltration. The appearance of IFP is pertinent to present as it raises suspicion for alternative more concerning diagnosis including GIST, cancer, or gastric lymphoma. The resection of IFPs has good clinical outcome.

V236

Laparoscopic Hepatectomy of the Middle Lobe

Yaojun Zhang, Yangxun Pan, Jinbin Chen, Li Xu, Dandan Hu; Sun Yat-Sen University Cancer Center

A 39-year-old female patient presented with a 55 × 40 mm liver mass in the middle lobe. She was clinically diagnosed to have primary liver cancer, with serum alpha fetoprotein (AFP) level 212.8 ng/ml. Surgical procedure are listed as below: 1) Dissect the ligamentum teres hepatis and falciform ligament, resect the gull bladder, explore of the size and location of the intrahepatic lesion with intraoperative laparoscopic ultrasound, apply hepatic portal blockage with Pringle’s Maneuver when necessary. 2) The left margin is along the right side of the falciform ligament, dissect the liver parenchyma with ultrasound knife to reach the secondary hepatic portal and anterior of the inferior vena cava. Special notice should be paid when dealing with the hepatic pedicle of segment IVa and IVb. 3) The inferior margin is along the hilar plate, dissect the liver parenchyma from left to right, towards the right anterior hepatic pedicle. 4) The right margin is marked by the right hepatic vein and the demarcation line of segment V and VI. The right margin was achieved through dissecting the liver parenchyma until the right anterior hepatic pedicle and the secondary liver portal. 5) Endo-GIA stapler was used to ligate the right anterior hepatic pedicle and the middle hepatic vein, and specimen was then removed. 6) The bleeding of the cutting surface was controlled by bipolar coagulation forceps, and right anterior hepatic pedicle was stitched with Prolene suture. A drainage tube was placed in the right subphrenic space, and specimen was taken out from the abdomen. Surgical duration was 128 minutes with 300 ml blood loss. The patients recovered well, she was dismissed from hospital 8 days postoperatively.

V237

Hemorrhage from the Inferior Vena Cava During Retroperitoneoscopic Adrenalectomy

Aurelio Francisco Aranzana Gomez, Jara Hernandez Gutierrez, Juan S Malo Corral, Beatriz Muñoz Jimenez; CH Toledo

Introduction: The posterior retroperitoneoscopic adrenalectomy (PRA), described in 1995 (Waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. The advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient.

The objective is to demonstrate the safety and efficacy of the retroperitoneoscopic approach for selected cases. We present a video that includes a clinical case with this technique.

Methods and Procedures: 58 year old women AP-laparotomic cholecystectomy, post-cholecystectomy pancreatitis, HT, cesarean section. Follow-up for bilateral SR adenomas and subclinical Cushing with hypertension (normal catecholamines, post-dexamethasone cortisol: 2.7). CT: Nodule of 38 × 29 mm suggestive of adenoma, and a nonspecific nodular thickening in left SR. Physical examination IMC-27, scars of medial laparotomy, subcostal and infraumbilical.

Results: Decubitus prone Jackknife position. Access through 2-cm minilaparotomy before and below the tip of the 12th rib. Creation of space by digital dissection. 3 Trocars. Pneumoretroperitoneum at high flow (25 mmHg). Opening of the Zuckerkandl fascia and localization of the superior renal pole, identification of the peritoneum and posterior muscular plane. Dissection of medial edge of the adrenal gland. Attention cava perforation at the level of the ostium of the SRD vein, we proceed to raise the intraabdominal pressure to 30 mmHg, avoid aspiration, mobilization of the gland for better access and subsequent control with clips, no drainage and control of adrenal vessels. Definitive result of the specimen: adenoma.

Conclusion(s): In selected cases, the retroperitoneal approach in prone position for the resection of the adrenal gland is safe and effective. It offers quick access to the gland along with the advantages of the minimally invasive approach. Although it needs to be performed by experienced surgeons due to its great complexity and technical requirements.

V238

Robot Assisted difficult splenectomy due to splenomegaly with multiple abscesses & perisplenitis in a post-stem cell transplant patient

Gabriela M Aguiluz, MD, Roberto Bustos, MD, Valentina Valle, MD, Sam Papasotiriou, Pier C Giulianotti, MD, FACS; University of Illinois Hospital & Health Sciences System

This is a case of a patient on status post stem cell transplant and extensive infectious history, referred to surgery due to multiple splenic abscesses, splenic sequestration and pancytopenia that successfully underwent robot-assisted splenectomy.

A 53-year-old male, with history of myelofibrosis, post stem cell transplant, pancytopenic, presenting epistaxis and hematuria, and a recent admission due to cellulitis of inferior member, is referred to surgery for splenectomy due to multiple abscesses and splenic sequestration. The patient underwent a robot-assisted splenectomy. The procedure was carried out with no complications. The operative times was 222 min, with an estimated blood loss of 150 cc.

The postoperative course was uneventful and the patient was discharged on postoperative day 6. Pathology reported spleen measuring 19.2 × 14.3 × 8.5 with multiple targetoid regions of coagulative necrosis with surrounding palisading histocytes and Langhans cells. 1 month post surgery, patient presented with improved platelet count and WBC, resolution of epistaxis and reduced hematuria.

Resection of large spleen in a minimally invasive fashion was successful in an immunocompromised patient with multiple splenic abscesses with a careful and precise dissection.

V239

Laparoscopic Witzel: A Better Jejunostomy Tube

Ciara R Huntington, MD1, Ryan C Pickens, MD 2, Thomas R Huntington, MD1; 1Huntington Laparoscopy, 2Atrium Health/Carolina Medical Center

Feeding jejunostomy tubes are a critical means of enteral nutritional support for patients who have foregut pathology. All surgeons should feel comfortable with placement of feeding jejunostomy tube – yet, many surgeons resort to an open approach due to the perceived difficulty of a laparoscopic approach including suturing and securing the tube. Surgeons who employ open techniques often utilize the Witzel approach, where the tube is secured by suturing bowel around the tube and then to the abdominal wall. The Witzel tube placement minimizes leaks and complications by placing the exit to the skin far from the entrance of the tube into the bowel. In this video, we present a laparoscopic Witzel approach for placement of feeding jejunostomy tube.

This approach combines the advantages of the traditional Witzel technique with the superb visualization and fast recovery of laparoscopy. To perform the technique, loop of jejunum is selected 30-40cm from the Ligament of Treitz. A laparoscopic stay stitch secures the bowel to the anterior abdominal wall. The use of an external knot pusher allows the laparoscopic surgeon to keep tension on the knots and move through the operation efficiently – however, internal knot tying can also be used if desired. An introducer needle is tunneled through the muscular layer of the distal limb of jejunum into the lumen; position is tested by insufflating the lumen with a syringe full of air. Next, the guide wire followed by jejunostomy tube are introduced into distal bowel. Using laparoscopic vicryl stitches, the laparoscopic Witzel is now performed with 3–4 stitches. A “bite” is taken from the bowel on one side of the tube, then the bowel on the other side of the tube, and finally the needle is passed through the abdominal wall. This allows small bowel to cover the tube and be fixed firmly to the abdominal wall. This is repeated until the tube is completely covered. Care is taken not to incorporate the tube into the stitches. The balloon is inflated with 3 ml sterile water, and the jejunostomy tube is tested and checked. This technique allows for placement of efficient and secure distal feeding access, incorporating the surgical technique of tried-and-tested open approach into the minimally invasive setting.

V240

Gastric remnant volvulus after conversion of Gastric Plication to RYGBP

Enrique Arias, MD, Luis Martinez, MD, Angel Henriquez, MD; INTERLAP

Case Presentation: A 31-year-old female had a gastric plication for morbid obesity treatment 5 years ago in another institution, her initial BMI was 40 kg/m2. During a year she lost 30 kg and had a BMI of 28 kg/m2. 18 months after the surgery she started to regain weight, and her final BMI was 42 kg/m2. Laparoscopic conversion to a RYGBP was performed, a 50 ml gastric pouch was created and gastric remnant was left with good irrigation. Mesenteric and Petersen defects were closed using a not absorbable suture, and she was discharged from the hospital 48 hours after the surgery. 3 days after hospital discharge she suffered from 24 hours of abdominal pain and vomits and was readmitted into the hospital. X ray didn’t show any abnormality, and the endoscopy reported no obstruction in GY junction, during her hospital stay she presented tachycardia and her abdominal pain persisted, so a diagnostic laparoscopy was indicated, during surgery gastric remnant dilation without dilation of biliopancreatic limb was found, after decompression of gastric remnant we identified an adhesion of omentum to the gastric remnant causing remnant rotation and a type of gastric volvulus. Resection of gastric remnant was done and the patient had uneventfully recovered

V241

Giant hiatal Hernia Associated to Acalasia, a Lot of Danger!

Jara Hernandez Gutierrez, Aurelio Aranzana, Beatriz Muñoz Jimenez, Juan S Malo Corral; CH Toledo

Introduction: Achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus.

The association of a long-term achalasia and a large size hiatus hernia is an infrequent entity, making it difficult not only to diagnose it but also to treat it. Among the therapeutic options is medical treatment, endoscopic treatment either dilatation or POEM, and surgical treatment associated with an antireflux procedure, with the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences.

The objective of this VIDEO is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure.

Methods and Procedures: 73-year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. The complementary explorations and iconography of interest are exposed, highlighting esophageal manometry.

Results: Preoperative optimization with respiratory and cardiological prehabilitation.

Intervention: complete endoscopic approach, 5 trocars. Reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. Extended mediastinal esophageal dissection. Complete resection of both the sac and lipoma, respecting the posterior vagus. Heller’s myotomy of 10 cm, including 3 cm distal to the UEG, perforation of 3 mm of the mucosa at the UEG level, suture and blue methylene verification of the sealing of the same. Hiatorraphy and Dor-type anterior fundoplication as antireflux technique. Correct postoperative, with EGD control on the 3rd PO day and discharge on the 6th. Asymptomatic at 12 months after surgery.

Conclusion: For patients who are at low surgical risk laparoscopic Heller myotomy with a partial fundoplication should be the treatment of choice to treat achalasia. The length of the myotomy, especially distal to UEG is one of the most important aspects of the surgery, most authors recommend that the myotomy extend 1–2 cm in the stomach, even up to 3 cm below the UEG to achieve an effective disruption of the LES. The presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, as in this case of perforation. Standardization is essential to increase safety and efficacy in these more complex cases.

V242

Robotic Parenchyma Sparing Central Pancreatectomy for a Mucinous Lesion of the Head and Neck of the Pancreas

Roberto Bustos, MD, Valentina Valle, MD, Alberto Mangano, MD, Sam Papasotiriou, Pier C Giulianotti, MD, FACS; University of Illinois at Chicago

Introduction: Central pancreatectomy is among the techniques available for the treatment of pancreatic neck tumors. It is indicated for benign or low-grade malignant neoplasms. This pancreas-sparing technique was developed to avoid exocrine and/or endocrine insufficiency that could be detrimental to the patient’s quality of life. Robotic central pancreatic resection has been used increasingly used since the first report in 2004 by our team. However, patients who require central pancreatectomy are often still treated by open or laparoscopic distal pancreatectomy.

Methods and procedures: 46-year-old female. PMH: diabetes mellitus, hypertension, dyslipidemia, obesity and hypersensitivity lung disease. HPI: episodic sharp abdominal pain radiated to the back and started 3 months before. CT scan: cystic lesion at the pancreatic head/neck junction (3.2 × 6.6 × 3.2 cm). EUS-FNA: suspicious for intraductal papillary mucinous neoplasm. Blood tests: elevated amylase and CEA.

Results: Surgical procedure: robotic laparoscopic central pancreatectomy with distal pancreaticogastrostomy. During the preparation of the pancreatic neck, inflammatory adhesions of the mucinous cyst to the portal vein had to be carefully dissected by microscissors. After the pancreatic parenchyma was divided, intraoperative frozen pathology reported no malignancy or severe dysplasia. Decision was taken to preserve the distal pancreas and also the pancreatic head in order to decrease the risk of endocrine/exocrine insufficiency. An end-to-side pancreaticogastrostomy was performed using a PDS 3-0 running suture posteriorly and interrupted PDS 3-0 stitches anteriorly. Post operatory course was uneventful. Patient discharged on POD7. No pain or steatorrhea after 1 month follow up. Pathology report: IgG4-related disease, associated with cystic formation negative for PanIN and carcinoma.

Conclusions: Robotic central pancreatic resection is a safe and feasible approach which can avoid endocrine/exocrine insufficiency (in particular for benign/low-grade malignant neoplasms). The Robotic platform, given the improved dexterity, the 3D stereotactic vision, and the better tissue manipulation, if used with a standardized technique in high expertise centers can be advantageous (in particular when adhesions are present).

V243

Robotic Transhiatal Esophageal Leiomyoma Resection

James Kurtz, DO, Edward Cho, MD, Houssam Osman, MD, Rohan Jeyarajah, MD; Methodist Richardson Medical Center

Introduction: Esophageal leiomyomas are rare benign tumors that can be adequately treated with limited resection or enucleation.

Case: We present a video case of a large, symptomatic distal esophageal leiomyoma requiring enucleation. We performed a robotic transhiatal approach to remove this mass. This case included an esophageal myotomy (with subsequent closure) to access the mass, a primary repair of hiatal hernia, and a Dor fundoplication.

Discussion: Large, symptomatic esophageal leiomyomas of the distal esophagus may be safely enucleated by a robotic transhiatal approach. The robotic approach may help avoid a more extensive resection if excision is deemed necessary for these benign lesions.

V244

Robotic Duodenojejunostomy for Superior Mesenteric Artery Syndrome

Alexandra Leon Guerrero, Caitlin C Houghton, MD; University of Southern California

We present a case of superior mesenteric artery syndrome treated surgically with a robotic duodenojejunostomy. This video demonstrates another application for the robot for an uncommonly performed foregut procedure.

V245

Robotic Repair of Recurrent Right Inguinal Hernia in a Patient with Prior Radical Prostatectomy

Parth Sharma, MD, Georgios Orthopoulos, MD, PhD, Mazen Al-Mansour, MD; Baystate Medical Center

Case Presentation: A 67 year old male patient with a previous open right inguinal hernia repair, as well as previous robotic prostatectomy with pelvic lymph node dissection presented to the general surgery office with a painful right groin bulge, worsening over 2 years. He was taken to the operating room electively for robotic right recurrent inguinal hernia repair. The accompanying video demonstrates the technique used to repair the defect without injuring critical structures, especially considering the previously violated tissue planes.

Operation: A pre-peritoneal plane was created by incising the right lower quadrant peritoneum. Meticulous dissection was then conducted from medial to lateral along the pre-peritoneal space as significant post-operative adhesions were encountered. Notably, a three-way urinary catheter was used to distend the bladder with normal saline in order to protect it during the difficult dissection. An indirect hernia sac was encountered within the adhesions. The hernia sac was inadvertently entered, and although all attempts were made to fully reduce the hernia sac, the herniating peritoneum was ultimately transected and partially reduced into the intra-abdominal space. There were no bowel loops noted within the hernia. After confirming clearance of the internal inguinal ring, a 3DMax Light mesh was placed into the pre-peritoneal space. The medial portion of the mesh was buried deep near the Pubic Symphysis and Cooper’s Ligament, and adequate coverage was achieved laterally to close the defect. The peritoneal flap was then closed primarily with 2-0 V lock sutures in running fashion. The opened peritoneal defect was also primarily ligated with 2-0 V lock suture. The patient had no hernia recurrence on follow-up, and aside from a small post-operative seroma he did well thereafter.

Learning Points: Inguinal hernia repairs in patients with prior open inguinal canal and pre-peritoneal surgeries can be quite challenging. Prior operative reports can augment pre-operative planning. Infusing saline through a 3-way Foley catheter can also help define bladder borders in order to avoid injury. Transecting the indirect hernia sac is acceptable, especially to avoid spermatic cord structures and iliac vessels. The peritoneal defect must be closed if a non-barrier coated mesh is used, in order to separate mesh from bowel. Finally, the robotic platform is particularly advantageous due to enhanced visualization, surgeon-controlled camera movement, wristed instruments, and ergonomic benefits during prolonged cases (as if often the case when working with post-operative scarring and adhesions).

V246

Robotic-Assisted Excision of Retroperitoneal Mass

Alexander L Marinica, DO, Lindsay A Nelson, DO, Fazal Din Moghul, DO, Abubaker Ali, MD, FACS; Detroit Medical Center - Sinai Grace Hospital

This is a case presentation of the excision of a retroperitoneal mass using the robotic platform. The patient is a 61-year-old male who presented with left lower quadrant abdominal pain for two months, and associated weight loss, nausea, vomiting, and constipation. Of note, he was in a car accident approximately seven years prior, and was not aware he had a left-side retroperitoneal cyst before that hospital admission. Abdominal CT imaging revealed a large isolated cystic mass, measuring 8.7 × 8.1 × 7.8 cm, representing a cyst. Robotic excision was performed via a four-port, transabdominal, transperitoneal, laparoscopic approach. The procedure was complicated by accidental thermal injury to the left ureter. The Urology service was consulted intraoperatively, performing a cystogram and ureteroscopy with no occult injury noted. A stent was placed at this time, to guard against development of a complication from a delayed thermal injury. Final pathology showed benign, non-epithelial cystic structure that was fibromembranous with chronic inflammation and congestion, negative for malignancy. The patient was found stable for discharge on post-operative day one. The stent was left in place for three months and removed by the Urologist in the office. The patient was seen three months post-op, his pain controlled and having no further issues. Although this case was complicated by an accidental ureter injury, we demonstrate a method by which to recognize and address this complication definitively. This case is a demonstration of the safe excision of a retroperitoneal mass using the robotic platform.

V247

Laparoscopic right hemicolectomy for cecal adenocarcinoma using suspensory suture technique for intracorporeal anastomosis

Francisco Benavides, MD, Thushy Siva, MD, Avian Chang, MD, Savni Satoskar, MD, Joshua Ziehm, DO, Vinay Bajaj, MD, Anthony Dippolito, MD, MBA, FACS; Easton Hospital

In this video we demonstrate a technique for performing an intracorporeal anastomosis during a laparoscopic right hemicolectomy for a cecal adenocarcinoma. The patient is placed in a supine position and four ports are placed: A 15-mm port at the umbilicus using open Hasson technique, a 12-mm right upper quadrant port, a 12-mm left lower quadrant port, and a 5-mm left upper quadrant port. After proper dissection and mobilization of the cecum, ascending colon, hepatic flexure, and transverse colon, the terminal ileum and proximal transverse colon are each transected using an endoscopic stapler and the specimen is placed above the liver for retrieval and extraction later. The proximal and distal anastomotic bowel segments are then placed in close proximity to the right upper quadrant port. Suspending sutures are placed through the anterior abdominal wall and through the staple line of the ileum and transverse colon and then back out through the abdominal wall. The suture loops are secured externally using a hemostat. Next, enterotomies are made over the staple line of the ileum and transverse colon. An endostapler is passed through the right upper quadrant port site and a side to side anastomosis is constructed while the bowel is stabilized using the suspensory sutures. A second load is used to ensure sufficient anastomotic length. The stapler is reloaded and passed through the left lower quadrant port and fired transversely to complete the anastomosis. The resected bowel is then placed in an endoscopic retrieval bag along with the anastomotic fragments and removed from the umbilical port site.

V248

Laparoscopic Roux-en-Y Gastric Bypass in the Setting of Unknown Malrotation

Elisabeth Wynne, MD, Shahroz Fatima, BS, Shaina R Eckhouse, MD; Washington University School of Medicine

Malrotation of the small bowel is a rare finding that affects 1 out of 6,000 births. Over 90% are diagnosed right at birth, and as such, it is rare to identify in adults. Only a few case studies exist in the literature regarding malrotation in patients undergoing laparoscopic Roux-en-Y gastric bypass. The video presents malrotation of the small bowel identified at the time of surgery in a 61-year-old female with a history of a laparoscopic sleeve gastrectomy now with gastroesophageal reflux disease (GERD) refractory to medical management and morbid obesity with a BMI of 36.3. After undergoing a work for GERD, the patient agreed to move forward with a laparoscopic Roux-en-Y gastric bypass to treat both her GERD and morbid obesity. At the time of the operation, the patient was identified to have non-rotation of her intestines, where her jejunoileal loops were on the right side of the abdomen and her colon was on the left side of her abdomen. The video presentation demonstrates the technique utilized to successfully perform a laparoscopic Roux-en-Y gastric bypass in the setting of the rare finding of malrotation.

V249

Removal of an adjustable gastric band that eroded into the liver

Kais A Rona, MD, Milton Tyler, Christopher Ducoin, MD; Tulane University School of Medicine

The adjustable gastric band has fallen out of favor secondary to high complication rates. Postoperative complications such as band slippage and erosion are not uncommon. In this video we demonstrate the laparoscopic removal of a gastric band that had eroded into the liver causing gastrointestinal symptoms including abdominal pain and per oral intolerance.

V250

Laparoscopic repair of incarcerated morgagni hernia

Derek Tessman, DO, Saad Shebrain, MD; Western Michigan University School of Medicine

Objective: The following video demonstrates a case presentation of incarcerated Morgagni hernia with successful laparoscopic transabdominal mesh repair.

Methods: A 34-year-old morbidly obese female with 18-months history of intermittent, sharp epigastric and chest pain, associated with episodes of SOB. The pain increases after eating and before Bowel movement, but partially relived by bowel movement. Physical exam findings were unremarkable except for morbidly obesity and the presence of mild tenderness in the epigastric area. Laboratory tests were unremarkable. A CT scan of the abdomen showed incarcerated Morgagni hernia containing omentum and transverse colon. Surgery was indicated.

Procedure: The patient was taken to the Operating Room for laparoscopic repair. Three ports were utilized with the 12 mm trocar placed in left upper quadrant, two 5 mm trocars in the supraumbilical and RUQ area. There were significant adhesions between the omentum/transverse mesocolon and hernia sac/defect. With gentle manipulation, the herniated omentum was carefully reduced. This was sharply and bluntly dissected. Transverse colon was reduced.

The adhesions between the hernia sac and defect were taken down. The hernia defect was cleared off adhesions and the falciform ligament was taken down. Given the chronicity and location of hernia, and weighing the risk/benefits, the decision was made not to excise the sac. The posterior edge of the hernia (retrosternal part of diaphragm) and anterior abdominal wall were approximated, and the defect was found to be amenable to primary repair with minimal tension. Using Endo Close™ Trocar Site Closure Device, and Endo Stitch Suturing Device, a multiple trans fascial-to-hernia defect sutures were taken in a U-shaped manner, the defect was closed. A 10 × 15 cm Ventralight (polypropylene) mesh was then utilized to enforce the primary repair. An 0-Ethibond trans fascial U-shaped suture was passed through the center of the mesh and used as a fixation point. The perimeter of the mesh was attached to the abdominal wall and diaphragm using ProTack™ 5 mm Fixation Device Attention was made to avoid injury of the pericardial area. The reduced hernia contents were examined prior to removing the trocars and deflating the CO2 pneumoperitoneum.

Result: The patient did well after surgery. She was discharged home on POD2. A 1-year follow up: the patient is doing well both clinically and radiographically (CXR).

Conclusion: Laparoscopic repair of incarcerated Morgagni hernia with mesh is feasible, safe and effective, and can be performed in obese patients with good outcome.

V251

Laparoscopic Segmental Gastrectomy for a Mid-Stomach Gastrointestinal Stromal Tumor

Gabriela Chullo, Resident, Roser Termes, Resident, Ainitze Ibarzabal, Specialist, Dulce Momblan, Specialist, Victor Turrado, Specialist, Antonio Lacy, Specialist; Hospital Clinic de Barcelona

Introduction: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. GIST are considered a low malignancy tumors. The risk of recurrence is based on tumor size and mitotic index. Radical surgical resection is the standard treatment in localized primary GIST. Surgical margins of 10 mm free from tumor involvement are sufficient since surgical aggressiveness with wide margins of resection is not related to an increase in survival or decrease in the risk of relapse and, nevertheless, the involvement of the resection margins or simple enucleation of the tumor is subject to a high rate of relapse. GISTs rarely metastasize via the lymphatic system, so regional lymphadenectomy would not be necessary.

Laparoscopic resection has been increasingly adopted, being widely accepted as a reasonable approach to treat GIST with reported similar operative time and survival rates, but shorter hospital stay compared with open resection.

In this video we show a mid gastric resection and anastomosis of a gastric GIST.

Methods and procedures: We present the case of a 67-year-old female patient diagnosed in July 2017 with gastric GIST following abdominal discomfort and dyspepsia. The gastroscopy showed a mid-stomach lesion without ulceration or mucosal involvement. Computed tomography (CT) showed a submucosal gastric tumor, depending on the anterior wall of the gastric body. The tumor had a maximum diameter of 57 mm and suggested a GIST. No signs of dissemination were observed.

Endoscopic ultrasonography showed a well-defined, hypoechoic and heterogeneous lesion measuring 53 × 51 mm in diameter and the ultrasound-guided needle biopsy confirmed GIST, positive immunohistochemical staining of CD117.

The patient received neoadjuvant treatment with Imatinib during 10 months, showing mild radiological response.

Laparoscopic resection in the mid-stomach was successfully performed. A side to side anastomosis was performed with manual suture.

Results: The operation time was performed in 180 minutes, no intraoperative complications occurred, and clear fluid intake was started on the first post-operative day. The patient had an uneventful postoperative course, and a hospital stay of three days.

The histological result showed a 70 × 50 × 40 mm tumor with low mitotic index and negative surgical margins.

The patient actually is asymptomatic and re-started the treatment with Imatinib.

Conclusions: In patients with resectable GIST, surgery continues to be the best treatment. Laparoscopic surgery is a safe and effective procedure, with excellent oncological results. Nevertheless, it is necessary to have experience in laparoscopic surgery to avoid tumor ruptures and minimize complications.

V252

Laparoscopic right hemicolectomy with CME: a caudal-to-cranial approach guided by duodenum

Wenjun Xiong, Wei Wang, Jin Wan; Guangdong Provincial Hospital of Chinese Medicine

In 2016, we first describe a caudal-to-cranial approach for laparoscopic right hemicolectomy. This approach was a safe alternative to the conventional medial-to-lateral approach, especially for inexperienced surgeons. As we all know, the duodenum is an organ passing through the retroperitoneum. Thus, we report a caudal-to-cranial approach guided by the duodenum for laparoscopic right hemicolectomy.

Step 1: Right Toldt’s space dissection

The "membranous bridge" between the mesentery and retroperitoneum was cut guided by the duodenum. The right Toldt’s fascia and the pancreatic duodenal anterior space are dissected with the pancreas and the posterior paries of superior mesenteric vein (SMV) exposed.

Step 2: Central vascular ligation

The mesocolon between the ileocolic vessels (ICVs) and SMV is dissected and the peritoneum on the surface of SMV is cut. The whole SMV is exposed. Then the ICVs, right colic vessels (RCVs), Henle’s trunk and the middle colic vessels (MCVs) are exposed. In this patient, the MCVs are defect. A central vascular ligation is performed to achieve CME.

Step 3: Cranial and lateral mobilization

The gastrocolic omentum is dissected for full mobilization of the mesocolon containing 10 cm of normal colon distal to the lesion. And the lateral attachments of the ascending colon is also separated.

V253

Laparoscopic Enterolithotomy for Gallstone Ileus

J. R. Salameh 1, Yewande R Alimi2; 1Virginia Hospital Center, 2Georgetown School of Medicine

Introduction: Gallstone ileus is a rare complication of gallstone disease. We report on a case of laparoscopic management of this condition.

Methods and procedures: This is a 71 year-old female who presented with a 10-day history of periumbilical abdominal pain, nausea and emesis. She had mild abdominal distension and generalized tenderness. CT Scan of the abdomen and pelvis demonstrated classic findings of gallstone ileus including pneumobilia, a cholecysto-duodenal fistula and a small bowel obstruction secondary to a gallstone impacted in the ileum.

Results: The patient underwent an uneventful laparoscopic enterolithotomy. She was discharged home on post-operative day 2 with no complications. She elected not to have a subsequent cholecystectomy and has not had any further symptoms at 18-month follow-up.

Conclusion: Laparoscopic enterolithotomy for the management of gallstone ileus provides an attractive alternative to laparotomy, specially in this usually elderly population.

V254

McKeown Esophagectomy. How we perform thoracoscopic time

Aurelio Francisco Aranzana Gomez, Jara Hernandez Gutierrez, Juan Malo Corral, Soledad Buitrago Sivianes, Rafael Lopez Pardo, Beatriz Muñoz Jimenez; Hospital Virgen De La Salud, Toledo

Objectives: We present a video that shows the thoracoscopic time of esophagectomy in three fields. To demonstrate the safety and efficacy of the minimally invasive approach in patients with malignant oesophageal pathology that require a total esophagectomy in three fields. The advantages of performing this technique is the reduction of blood loss, decreased postoperative stay, lower morbidity and mortality than in conventional surgery, better analgesic control, smaller incisions minimizing operative aggression, favors the patient’s subsequent recovery and increases their quality of life. All these advantages have to be supported by an adequate selection of patients and an excellent preparation of the surgical team with extensive knowledge in laparoscopic surgery.

Results: We present a video that shows the standardized thoracoscopic time of a total esophagectomy. The position in prone position during thoracoscopy facilitates the vision of the structures and an adequate lung disposition without need of a separator.

Intervention: Prone decubitus, selective intubation. Approach by right thoracoscopy, 4 trocars. En bloc esophageal mobilization, including perisophageal pleura, with periesophageal, periaortic, peribronchial and subcarinal mediastinal lymphadenectomy, azygos vein section, resection and clipping of the duct thoracic, endothoracic drainage. The surgery is continued with a laparoscopic and left lateral cervical approach completing the proximal esophagogastrectomy with gastric esophago-tubular cervical anastomosis.

Conclusions: The minimally invasive surgery of esophageal cancer, by means of right thoracoscopy and prone decubitus is a valid and safe alternative to traditional surgery, and should be done in a standardized way and by teams with experience in this type of approach.

V255

Endoscopic placement of a GJ feeding tube as a one step procedure, a novel approach

Jason E Kuhn, DO, Robert Cunningham, MD, Jon Gabrielsen, MD, Anthony Petrick, MD, David Parker, MD; Geisinger Medical Center

Geisinger Medical Center is presenting a video submission for a novel endoscopic placement of a GJ feeding tube. Traditionally this tube is placed either in a two step endoscopic procedure, first with a PEG then removal after the tract matures and placement of the GJ tube or operatively. This technique demonstrates how the procedure can be done performed in a single stage.

V256

Robotic-Assisted Laparoscopic Redo Hiatal Hernia Repair with Redo Nissen Fundoplication

Usah Khrucharoen, Ian T Macqueen, Yijun Chen, Erik P Dutson; UCLA

Minimally-invasive techniques have been implemented in the repair of giant hiatal hernias with successful outcomes; however, recurrence rates have also been reported up to 30 to 40%. In this video, we demonstrated robotic-assisted laparoscopic redo hiatal hernia repair with redo Nissen fundoplication performed at our institution. Patient was a 53-year-old male with a history of laparoscopic repair of giant hiatal hernia with intrathoracic stomach, Nissen fundoplication with PEG tube gastropexy 9 months prior to his current procedure. His PEG tube spontaneously dislodged approximately one week postoperatively. Patient then developed recurrent reflux symptoms 6 weeks post-procedure. Further work up with CT abdomen revealed an evidence of a recurrence of his paraesophageal hiatal hernia measured up to 4.5 cm in craniocaudal dimension. Patient was desirous to proceed with operative management. Following taking down the adhesions and the prior wrap, revision of posterior cruroplasty and Nissen fundoplication was performed. A total of five linear sutured fixation points were used to create a 4-cm-long fundoplication. The superior aspect of the wrap was anchored to the anterior arch of the crura as well as the left and the right crura to prevent the wrap from sliding. In this case, the site of the prior PEG tube was still acting as a point of gastric fixation to the anterior abdominal wall. Operative time was 3 hours and 27 minutes. Blood loss was minimal. Postoperative course was unremarkable. Upper GI series on POD#2 demonstrated no leak, good angulation at His, and intact long wrap below the diaphragm. Patient was initiated clear liquid diet on POD#2 due to residual post-anesthetic nausea. He was discharged on POD#3, and was able to initiate soft diet without difficulty at 2-week postop.

V257

Laparoscopic Revision of a Paraesophageal Hernia

Alisan Fathalizadeh, MD, MPH, Joshua Landreneau, MD, John Rodriguez, MD, Kevin El-Hayek, MD; Cleveland Clinic Foundation

A hiatal hernia involves the herniation of the stomach above the diaphragm. Preoperative work-up generally involves the use of upper endoscopy and an upper GI study. Emergent repair is generally indicated when volvulus, bleeding, obstruction, strangulation, or perforation are encountered. Elective repair is generally performed with subacute symptoms, whereas, prophylactic repair is generally indicated if a greater than ten year life expectancy is anticipated. The patient presented underwent a laparoscopic paraesophageal hernia repair with subsequent recurrence and revision.

V258

Colonoscopic Assisted Robotic Resection (CARR): Descending Colon Submucosal Lipoma

Michael E Dolberg, MD, FACS, FASCRS; Memorial Healthcare System

Purpose: This video presents a case of a 46 year old female with a history of chronic left sided abdominal pain. A thorough evaluation was performed which included a colonoscopy. This exam revealed a large submucosal mass in the proximal descending colon with associated mucosal ulceration. A CT scan confirmed the presence of a 6 cm fat containing mass just distal to the splenic flexure without evidence of colonic obstruction. The patient was taken to the operating room for a Colonoscopic Assisted Robotic Resection (CARR) of the submucosal mass.

Methods: The patient received a full bowel preparation. The procedure was performed in the lithotomy position to allow for intra-operative colonoscopy. The abdomen was entered in the right upper quadrant with an 8 mm optical robotic port. Colonoscopy was performed which confirmed the presence of the submucosal mass in the proximal descending colon. This lesion was located at the anti-mesenteric border of the colon. The area was marked with clips. Four additional ports were placed along the right side of the abdomen. These ports included two additional 8 mm ports, a 12 mm port, and a 5 mm assistant port. Using cautery, a full thickness local resection of the mass was performed, including the involved ulcerated mucosa. The defect was then closed transversely using multiple firings with the robotic stapler.

Results: The patient was successfully treated with this robotic/endoscopic technique. She was tolerating a regular diet and passing flatus on POD 1. She was ready for discharge on POD 2. The patient was seen in the office 2 weeks following the procedure. Her chronic abdominal pain had completely resolved. The final pathology showed colonic tissue with a submucosal lipoma with areas of fat necrosis, overlying mucosal ulceration, and reactive changes.

Conclusions: Colonoscopic Assisted Robotic Resection (CARR) is a technique that can be used to remove benign masses from the colon without the need for a formal resection. The use of the colonoscope allows definitive localization of the lesion so that the colotomy can be made in the appropriate position. Review of this case did allow the authors to make recommendations for future use of the technique. Although hook cautery was used in this procedure, a scissor may have offered increased accuracy and less thermal spread. The colotomy was closed with the stapler in this resection. Primary sutured closure would likely have been easier, faster, and less expensive.

V259

Laparoscopic sleeve gastrectomy: Medial to lateral approach

Usah Khrucharoen, Yen-Yi Juo, Yijun Chen, Erik Dutson; UCLA

While no significant difference in weight-loss efficacy or safety has been demonstrated between a medial-to-lateral and a lateral-to-medial approach for laparoscopic sleeve gastrectomy, our institutional experience of over 900 patients suggested several technical advantages of the medial-to-lateral approach. In the current video, we seek to demonstrate the superior visualization of the gastric anatomy when the stomach was transected prior to division of the short gastric vessels. In addition, a more intuitive visual-spatial understanding of the location of the antrum in relation to the gastric body and incisura angularis could be achieved. Finally, we seek to demonstrate our technique of triangulation, using the greater omental attachment as a retraction handle to facilitate the division of the stomach.

V260

Laparoscopic Small Bowel Resection

Marcoandrea Giorgi, MD, Todd Stafford, MD; Brown University - Rhode Island Hospital

Video illustration of laparoscopic small bowel resection with anastomosis. Patient is a 33 years old female with history of malrotation and sleeve gastrectomy who presented with acute onset epigastric pain and was found to have closed loop obstruction on CT scan, She was taken emergently to the operating room and underwent laparoscopic resection and anastomosis

V261

Laparoscopic Esophageal Diverticulectomy

Elizabeth H Bruenderman, MD, Farid J Kehdy, MD; University of Louisville

Background: This video reviews a laparoscopic esophageal diverticulectomy. The patient is an 80-year old lady who presented as an outpatient with dysphagia, pain with swallowing, chest pain, mild dyspepsia, hoarseness, and regurgitation of undigested food. She underwent a diagnostic esophagogram, which revealed an outpouching in the distal esophagus. Subsequent esophagogastroduodenoscopy (EGD) was consistent with an esophageal diverticulum in the distal third of the esophagus, along with a hiatal hernia and a benign stricture at the gastroesophageal junction. After appropriate preoperative workup, a laparoscopic diverticulectomy with Heller myotomy and hiatal hernia repair was performed.

Methods: After entry into the abdomen, the esophagus was dissected circumferentially at the hiatus and into the mediastinum, in order to mobilize the distal esophagus into the abdominal cavity. The diverticulum was noted at the one to two o’clock position on the esophagus. Care was taken to avoid the vagus nerve, particularly the anterior branch, which coursed along the anterior surface of the diverticulum. Intraoperative EGD was used to delineate the extent of the diverticulum, which was resected using a stapler over a 56-French bougie. A Heller myotomy was performed, and the crura were then re-approximated.

Results: Postoperative esophagogram was without evidence of leak or residual diverticulum. Her postoperative course was unremarkable, and she was discharged home on postoperative day two. On follow-up, her symptoms had resolved, and she was tolerating a regular diet.

Conclusion: Laparoscopic esophageal diverticulectomy can be performed both safely and effectively for diverticula located in the distal esophagus.

V262

Laparoscopic Repair of a Lumbar Hernia

Jessica Pries, MD, William Richardson, MD; Ochsner Clinical Foundation

Lumbar hernias are a rare and challenging entity. They are bordered by the 12th rib superiorly, the iliac crest inferiorly, and the erector spineae muscles and external oblique on either side. Their close proximity to bony and neurovascular structures limit a surgeon’s options for repair. We present a patient with a superior lumbar hernia who underwent laparoscopic repair. She had a 2 cm defect repaired in the preperitoneal space utilizing primary suture repair and mesh reinforcement. The total operative time was 40 minutes. She went home on post operative day 1 after an uncomplicated hospital stay.

V263

Incidental Paraduodenal Hernia During Laparoscopic Gastric Bypass

Caitlin Polistena, MD, Diego Camacho, MD, FACS; Montefiore Medical Center

This is the case of an incidentally found left paraduodenal hernia during elective laparoscopic gastric bypass surgery. The patient is a 52 year old man with no prior history of intra-abdominal surgery who underwent multidisciplinary workup for bariatric surgery and was found to be an adequate candidate for the procedure. No imaging was performed prior to surgery. Upon entering the abdomen there was a distinct absence of small bowel. The ascending and descending mesocolon were noted to be fused in the midline, and the small bowel was found to be trapped in the left retroperitoneum. A lysis of adhesions was undertaken to free the small bowel all the way up to the ligament of treitz. The large defect in the transverse mesocolon was then closed and the proximal jejunum pexied to the transverse mesocolon. Once normal anatomy is restored the gastric bypass is performed in standard fashion.

V264

Splenic Hamartoma, an Inusual Case of Splenomegaly

Jara Hernandez Gutierrez, Aurelio Francisco Aranzana Gomez, Beatriz Muñoz Jimenez, Juan S Malo Corral; CH Toledo

Introduction: Splenic hamartoma is a rare benign tumor, of which about 150 cases have been described in the literature since it was first described by Rokitansky in 1861. It is usually a casual finding in laparotomies or autopsies. They are usually asymptomatic, but there are few symptomatic splenic hamartomas and they can be associated with haematological alterations, being in some cases associated with spontaneous splenic rupture and acute abdomen, two thirds of them have multiple tumors.

There are no specific data that allow the preoperative diagnosis of this entity, which is performed after the anatomopathological study of the surgical specimen, which must be extracted entirely, this together with the size of the spleen makes the laparoscopic approach difficult.

The aim of this video is to demonstrate the surgical technique of a complete laparoscopic approach for this type of lesions, without the need for assistance laparotomies (handport).

Methods and Procedures: Clinical case: A 44-year-old man admitted to Internal Medicine due to fever and left lumbar pain. Additional explorations of interest are discussed, including: Thrombopenia of probable peripheral origin secondary hypersplenism (FNA of bone marrow), CT: Splenomegaly with 4 splenic masses, which deform the splenic contour, compatible with atypical hemangiomas, without being able to discard other vascular splenic tumors.

Results: Complete semi-laparoscopic approach, 4 trocars, Multilobulated splenomegaly (19 × 16 cm), mechanical vascular section, complete bag extraction after minilaparotomy on the left flank. The patient presented a successful postoperative recovery, being discharged on the 4th PO day. Abdominal ultrasound at 1st week with portal vein thrombosis, which resolves after treatment with heparin. Definitive result of the specimen: multiple splenic hamartoma. Asymptomatic one year after surgery.

Conclusion(s): The laparoscopic approach is a valid and effective alternative to splenic benign tumor lesions. The size does not contraindicate this type of approach, although the complete extraction of the spleen is recommended for its pathologic study. We recommend eco-Doppler control per week, given the risk of portal thrombosis with an existing laparoscopic post-splenectomy.

V265

Hiatal Hernia Repair After Esophagectomy

Sean R Maloney 1, Christy M Dunst2, Walaa Abdelmoaty2, Paul D Colavita1; 1Carolinas Medical Center, 2The Oregon Clinic

Here we present two cases of hiatal hernia repair after esophagectomy. One shows the less complex anterior dissection and closure while the other required dissection in the posterior aspect, in proximity of the gastric conduit blood supply, for sufficient closure of the defect.

V266

Removal of a Fecal Mass Using TAMIS in a Patient with Imperforate Anus

Matthew Wynn, MD, Derrick Oaxaca, BS, Harriet Barratt, MD, Caesar Ricci, MD, Ziad Kronfol, MD; TTUHSC EP

Anorectal malformation (ARM) is an embryonic developmental disorder that occurs in 1 in 1500 to 5000 births. ARMs are typically diagnosed and repaired during the neonatal period or early childhood. Posterior sagittal anorectoplasty (PSARP) has been historically considered the gold standard technique for the treatment of ARM due to improved anatomical visualization, and can be used in neonates and pediatric patients, as well as in adults. However, both urinary and fecal function is often compromised after PSARP, even when optimal surgical management is performed. Patients with mild ARM commonly present with constipation for reasons that remain unidentified, but are likely due to malformations in anorectal innervation and rectosigmoid hypomotility. Chronically constipated patients with a history of treated ARM can have continued abnormalities related to intestinal function and colonic caliber, including fecal impaction and overflow encopresis, and often require oral fluid and enema symptomatic treatment. Severe chronic constipation in patients with ARM can also lead to a rare condition called megarectum. We present in this case report a 40 year old male with a past medical history of ARM, who sustained multiple injuries, including a traumatic brain injury, in a high speed motorcycle accident. Abdominal CT on admission incidentally demonstrated a large amount of fecal material impacted within the midsigmoid colon. The colon was focally dilated with subtle peripheral mesenteric inflammatory changes suggestive of stercoral colitis. Due to the inability to remove the mass safely using conventional methods, the mass was removed with the implementation of transanal minimally invasive surgery (TAMIS). To our knowledge, this is the first time that TAMIS has been used to manage an obstructing fecaloma. Further, this case report highlights a clinical scenario that must be suspected in a traumatic brain injury patient with a past medical history of imperforate anus.

V267

Large Paraesophageal Hernia with Gastric Volvulus

Consandre P Romain, MD, Benjamin R Biteman, MD; Mercy Health Youngstown

78 yo female presents to the ED with nausea, vomiting and abdominal pain for 2 days.

CT scan in the ED reveals large type IV paraesophageal hernia with gastric volvulus.

General surgery takes the patient to the OR for laparoscopic paraesophageal hernia repair.

V268

Robot Single Incision Left Lateral Sectionectomy via da Vinci® Xi™ Single Site™

Woochul Kim, MD; Seoul National University Bundang Hospital

Background: Ever since laparoscopic liver surgery was first introduced in the 1990s, surgeons began to explore ways to minimalize the number and size of incisions, and at the same time refining surgical techniques to reduce damage to adjacent organs. With such effort, robotic consoles like the Da Vinci® Surgical System were adapted throughout hospitals worldwide to provide better range of motion and camera angles in minimally invasive surgeries. Moreover, in recent times robotic surgeries are becoming more prevalent in complex hepatic surgeries.

This video shows a case of left lateral sectionectomy done via robotic device approached through a single incision site to a patient with metastatic breast cancer located in segment 2 of the liver.

Video Contents: The patient was put in a lithotomy position. A single 3 cm trans-umbilical incision was made. A robotic camera and two working arms were inserted through the glove port, which was previously implanted through the umbilical incision. Resection of the falciform ligament and mobilization of the left liver was performed. Line on the liver surface along the falciform ligament was marked using electrocauterization. Ultrasonography probe was placed on the liver surface to detect and visualize intersectal vessels around the resection plane within the liver parenchyma. Superficial and deep parenchymal dissection along the marked line was performed using the crushing method with bipolar electrocauterization. Further dissection was done with a monopolar device. The Glissonean pedicles to the left lateral section were isolated and ligated using the endoscopic stapler, which was inserted through the glove port. Left hepatic vein was identified and ligated by a Hem-o-Lok. The dismembered specimen was then placed in a plastic bag. Obstetrician came to extract the specimen through the post-culdotomy site, which was subsequently repaired by 2-0 interrupted Vicryl suture.

This operation took approximately 250 minutes and estimated blood loss was minimal. The patient was discharged 4 days after the operation without any significant postoperative complications. The final histopathologic report showed 2 metastatic breast cancer masses with clear resection margin.

Conclusion: This video demonstrates technical feasibility of left lateral sectionectomy using a robotic console approached through a single incision site.

V269

Robot-Assisted Laparoscopic Subtotal Cholecystectomy and Common Bile Duct Exploration

Subhashini Ayloo, MD, MPH, Jacob Schwartzman, MD; Rutgers, New Jersey Medical School

Objective: To demonstrate the safety and feasibility of minimally invasive robot-assisted bile duct exploration and subtotal cholecystectomy for Mirizzi syndrome.

Materials and Methods: A 42 year old woman presented with abdominal pain, cholangitis, and elevated LFT’s. Ultrasound confirmed cholelithiasis/choledocholithiasis. Two attempts of ERCP with EHL were unsuccessful in clearing the bile duct stones. Diagnostic imaging reconfirmed the findings of cholelithiasis and choledocholithiasis.

This video showcases the fine technical details of a minimally invasive robotic approach to bile duct exploration. Diagnostic laparoscopy showed no other pathology. The operation was commenced with a cholecystectomy, which showed the gallbladder to be chronically inflamed, thickened, and with tissue planes obliterated. The cystic duct and the neck of the gallbladder were firmly fused to the extrahepatic bile duct. Subtotal cholecystectomy was performed secondary to the extent of fistulization of the gallbladder to the extrahepatic duct, followed by exploration of the bile duct and removal of all the stones. Completion cholangiogram showed contrast filling the duodenum.

Conclusions: Minimally invasive subtotal cholecystectomy and CBD exploration for choledocholithiasis is safe and feasible. This could be an alternate option to address significant fistulization of gallbladder to the hepatic duct and when unsuspectedly encountered in the operating room to traditional Roux-en-Y Hepaticojejunostomy.

Educational/Technical Points: The camera is positioned in the right mid-abdomen. The surgeon’s left arm is positioned in the right lateral abdomen and the right arm is positioned peri-umbilically. The robotic 4th arm is positioned in the left mid-abdomen. A first assistant port is placed inferomedial to the surgeon’s left arm. The 4th arm is useful in providing cranial retraction of the liver or the fundus of the gallbladder. A vascular Fogarty is very helpful to retrieve stones that are impacted distal to the choledochotomy site in these MIS-HPB cases then the traditional biliary fogarty which is short in length.

V270

Laparoscopic Removal of a Non-adjustable Gastric Band and Conversion to Roux-en-Y Gastric Bypass

Agustin Duro, MD, Virginia M Cano Busnelli, MD, Patricia Saleg, MD, Fernando G Wright, MD, Axel F Beskow, MD; Hospital Italiano de Buenos Aires

Non-adjustable gastric banding, first introduced in the early 1980s, involved the placement of a silicone ring around the upper part of the stomach to restrict food intake and achieve weight loss. Despite initial promising results, complications and weight regain appeared in long-term follow up, necessitating reoperation for band correction or removal, and conversion to another bariatric procedure.

This video shows a 64-year-old woman with a BMI of 40, with history of hypothyroidism and asthma with a non-adjustable gastric band placed in the year 2000 in another hospital, who consulted for weight regain and gastroesophageal reflux disease (GERD) symptoms. A CT scan and a barium swallow revealed a dilated pouch and the band constricting the middle part of the gastric body. Operative technique included extensive lysis of adhesions between the left lateral sector of the liver and the stomach, complete band dissection, until a segment was found eroded into the gastric wall, partial gastrectomy of the fundus and the body and conversion to Roux-en-Y gastric bypass (RYGB). She had no postoperative complications and was discharged on the second postoperative day. At 3 months, she has lost 40% of her excess body weight and remains asymptomatic for GERD.

Like other revisional procedures, conversion from a non-adjustable gastric band to a RYGB can be technically demanding and with increased morbidity. However, in experienced groups, it seems to be safe and effective in terms of weight loss and resolution of GERD.

V271

Laparoscopic Morgagni Hernia Repair

Julia L Jones, MD, Douglas Fenton-Lee, MD, Jean Wong, MD, Aldenb Lorenzo, MD, Wendy S Liu, MD, Siddharth P Rajput, MD; St Vincent’s Hospital, Sydney

Morgagni hernia is a rare diaphragmatic hernia. It is formed in the retrosternal space by the failure of fusion of the diaphragm with the costal arches. It is usually detected and repaired in childhood, however some cases are detected incidentally in adulthood or are found upon investigation of cardiorespiratory symptoms.

We present the operative video of the laparoscopic repair of a Morgagni hernia in a 62 year old gentleman who presented with progressive dyspnoea and exercise intolerance. The hernia was repaired using a combination of primary closure & mesh reinforcement, the video seeks to show the critical, technical steps in achieving a successful laparoscopic repair.

V272

Laparoscopic Nissen Fundoplication: An Educational Video

Breanna Fang, Jerry T Dang, MD, Shahzeer Karmali, MD, MPH; University of Alberta

The objective of this video was to provide an educational tool for surgical trainees to learn the operational steps of a laparoscopic Nissen fundoplication. Laparoscopic Nissen fundoplication is a key component in the management of gastroesophageal reflux disease and an essential procedure in the training of General Surgery residents. However, volume and exposure can vary among surgical residency programs. Particularly in the case of advanced laparoscopic procedures, studies have demonstrated low exposure rates at many teaching hospitals. There is a need for alternative methods for surgical trainees to learn about procedures such as the Nissen fundoplication.

We present an educational video of Nissen fundoplication performed by an experienced, fellowship-trained minimally invasive surgeon. Each step of fundoplication is explained and demonstrated for the optimal trainee learning experience.

V273

Robotic THE

Sharona Ross, MD, FACS, Janelle Spence, Iswanto Sucandy, MD, Alexander Rosemurgy, MD, FACS; Florida Hospital Tampa

Introduction: Esophageal cancer is an uncommon, yet lethal disease accounting for 1% of cancers diagnosed in the United States, and it is the seventh cause of cancer related death among men. As for any disease, it is important for surgeons to assess the benefits and drawbacks of different operative techniques, especially concerning upcoming, essential developments such as the robotic approach. This video documents a robotic transhiatal esophagectomy undertaken in a 65-year-old gentleman with a very large tumor in the distal esophagus.

Methods and Procedures: Technique of robotic transhiatal esophagectomy is described. A video is attached to this report.

Results: A 12 mm port was placed at the umbilicus and two 8 mm ports were placed to the right and left of the umbilicus at the mid-clavicular line. Two 5 mm ports were placed cephalad to the umbilicus on the right and left auxiliary lines, respectively. Finally, a Gelport® was place in the right lower quadrant. The gastrohepatic omentum was opened and then the stomach and duodenum were mobilized. A wide Kocher maneuver was undertaken, and great care was taken to preserve the right gastroepiploic and right gastric arteries. Dissection was carried up into the mediastinum. A pyloromyotomy was undertaken. Vascular and purple-load Endo-GIA staplers were used to divide the left gastric artery at its origin and the proximal stomach. An incision was made on the border of the sternocleidomastoid muscle and dissection began with careful attention to adjacent nerves and vessels. The esophagus was mobilized in the neck and divided. The specimen was removed after being brought into the peritoneal cavity. The stomach was brought up into the neck and stapled esophagogastrostomy was constructed. Interrupted silk sutures were used to close the anastomosis. The stomach was sewn into the crura to avoid any torsion that would threaten the anastomosis. The trocar sites were closed absorbable sutures. A Jackson-Pratt drain was placed in the neck incision, which was closed with interrupted Vicryl sutures.

Conclusion: The robotic approach for transhiatal esophagectomy offers an alternative to conventional laparoscopy. The application of robotic transhiatal esophagectomy is highly encouraged and surgeons should implement this approach into their armamentarium.

V274

Robotic Transanal Excision of a Large Rectal Polyp

Adam Studniarek, MD, Matthew Ng, MD, Gerald Gantt, MD, Mohammad Shokouh-Amiri, MD, Anders Mellgren, MD, PhD, Johan Nordenstam, MD, PhD; University of Illinois at Chicago

Background: Transanal minimally invasive surgery (TAMIS) was originally introduced as a hybrid technique between Transanal Endoscopic Surgery (TEM) and single site laparoscopy for resection of benign and early-staged malignant rectal lesions. Originally described in 2010 by Attalah et al, TAMIS was designed to allow access to mid-rectal and more proximal lesions. The continued evolution of minimally invasive techniques and the advantages of robotic surgery introduced a concept of robotic surgery in rectal lesions. Experimental work in cadaveric models has confirmed that Robotic TAMIS (R-TAMIS) is a potential option. R-TAMIS is still considered to be a novel technique among colorectal surgeons.

Case report: A 57-year old male presented with a 3 year history of hematochezia. From an outside facility, the patient was diagnosed with a large rectal mass located 6 cm from the anal verge. The biopsy demonstrated tubullovillous adenoma, negative for high grade dysplasia. Endoscopic rectal ultrasound (ERUS) demonstrated a mass located in the right posterolateral rectal wall with submucosal invasion but no extension into the muscularis propria. No evidence of lymphadenopathy was noted. The decision was made to proceed with R-TAMIS for full thickness excision of the large rectal mass. In the operating room, the patient was placed in the right lateral decubitus position and GelPoint platform was inserted into the anal canal. Full thickness excision of the pedunculated rectal mass was performed. The defect was closed using 3-0 running v-loc sutures. Following the surgery, patient was admitted overnight for observation and discharged home the next day. The surgical biopsy demonstrated T1, sm1 well differentiated adenocarcinoma.

Discussion: The use of a robotic system in transanal surgery is the most recent evolution of natural orifice surgery for the treatment of low risk rectal lesions. We present a case of a successful full thickness transanal excision of a large rectal polyp using R-TAMIS technique. The advantages of robotic system in a small confined space of the pelvis allows for an adequate resection with improved visualization in comparison to conventional methods. Robotic transanal minimally invasive surgery is a viable option for resection of early stage rectal lesions.

V275

Laparoscopic approach to Incarcerated paraesophageal hernia and Endoscopic Per-oral Pyloromyotomy after Open Ivor-Lewis Esophagectomy

Maria C Fonseca, MD, Cristian A Milla Matute, MD, Fernando Sarmiento-Cobos, MD, Armando Rosales, Tolga Erim, DO, Samuel Szomstein, MD, FACS, FASMBS, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Open Esophagectomy is a complex procedure with potential morbidity. Among its complications are Hiatal hernias and anastomotic stricture. The later accounts for 10–40% of the cases and most of them result in anastomotic leaks. However, in rare cases, development of symptomatic High-Grade (type IV) Paraoesophageal hernia can be seen. Considering the anatomy of the hiatus, paraoesophageal hernia incarceration is a rare but morbid complication and has to be addressed carefully. The purpose of this video is to present a case of a 55-year-old male with history of open Ivor-Lewis esophagectomy complicated by stricture, dilatation, stent and perforation, who was admitted with signs and symptoms of distal obstruction secondary to incarcerated paraesophageal hernia. An anterior approach for Hiatal hernia repair and per-oral pyloromyotomy where performed to achieve full recovery of the patient.

V276

Robotic Distal Gastrectomy for refractory peptic ulcer disease

Roberto Bustos, MD, Gabriela Aguiluz, MD, Alberto Mangano, MD, Yevhen Pavelko, MD, Luis Gonzalez, MD, Mario Masrur, MD, FACS; University of Illinois at Chicago

Introduction: Adults with Sickle Cell Disease can be at increased risk of H. pylori-induced Peptic Ulcers. Moreover, these patients can develop complications related to pre-existing chronic anemia, excessive use of NSAIDs, and alloimmunization which in turn may delay transfusion. Despite of the effectiveness of the PPIs and eradication of H. pylori by antibiotics, surgical treatment is still an option. In particular, this is true when bleeding ulcers are refractory to medical treatment or when malignant ulcers are diagnosed.

Methods: 56-year-old female. History of sickle cell disease with multiple complications (vaso-occlusive crisis, acute coronary syndrome, recurrent interstitial pneumonia, avascular necrosis of the hip and acute kidney failure). HPI: long-standing peptic ulcer disease with H. pylori infection and multiple episodes of GI bleed requiring cauterization.

Results: A Robotic-assisted distal gastrectomy with Roux-en-Y reconstruction was performed. An extensive adhesiolysis was required to gain access to the lesser curvature. The gastrojejunostomy was constructed using a linear stapler (purple load). Gastrostomy and enterotomy were closed with a single layer 3-0 PDS running suture.

Conclusions: Surgical treatment for peptic ulcer disease has become less common due to the effectiveness of medical treatment. Nevertheless, in some specific situations, surgical treatment is indicated and minimally invasive approach using the robotic platform is a feasible alternative.

V277

Laparoscopic Robotic-Assisted Paraesophageal Hernia Repair and Gastric Gist Resection

Enrique F Elli, MD, FACS, Tamara Diaz Vico, MD; Mayo Clinic Florida

A 76 years-old patient, with no surgical background, was found to be anemic while suffering flu-like symptoms. Preoperative studies were performed in order to reach a final diagnosis. There were no pathological findings in the colonoscopy. The EGD showed a mass in the proximal stomach measuring 4 to 5 cm. It was biopsied, demonstrating bland spindle cells with inmunohistochemical features consistent with gastrointestinal stromal tumor (GIST). The upper GI evidenced a paraesophageal hernia, and the mass described in the EGD too.

Patient was selected to undergo a laparoscopic robotic-assisted paraesophageal hernia repair and gastric GIST resection.

The procedure started with a diagnostic laparoscopy, showing a hiatal herniation with migration of the stomach into the mediastinum. A tattooed mass compatible with the description in the EGD came out during the manipulation of the stomach. Short gastric vessels were divided, as well as the gastroesplenic ligament. Left crus was then exposed. Dissection continued by opening the pars flaccida and dissecting the right crus. Then, the hernial sac was carefully dissected on both sides. The vague nerve was isolated and preserved and, once the dissection in the mediastinum was finished, the hernial sac was removed. A retroesophageal tunnel was created and a Penrose drain was passed along for retraction and exposure. An intraoperative endoscopy confirmed the location of the gastric tumor and a 54 Taper bougie was introduced to guide the resection. Then, a gastrotomy was performed and the GIST was exposed. An endoGIA with two white loads were fired across and the staple line was reinforced with 3-0 PDS suture in an interrupted fashion. The gastrotomy was closed with 2-0 V-Loc suture in a running fashion, reinforcing it with interrupted stitches of 3-0 PDS.

Once the closure of the gastrotomy was finished, the pillars of the hiatus were approximated with interrupted stitches of 2-0 Ethibond. An anterior interrupted stitch was placed to restored the anatomy. While performing the fundoplication, several nodules were identified and removed from the distal esophagus. Pathology report confirmed the diagnosis of leiomyomas. Lastly, a Toupet fundoplication was performed using interrupted absorbable sutures.

The operative room time was 330 minutes. No intraoperative complications occurred. The postoperative course was uneventful, and the patient was discharge on postoperative day 3. The upper GI showed no leaks, and the pathology report described a gastrointestinal stromal tumor with a G1 histological grade, and positive CD117 and CD34 in inmunohistochemical studies.

V278

Successful Laparoscopic Sleeve Gastrectomy After Severe Pancreatitis

Kenneth Copperwheat, DO, Gerrit Dunford, MD, Patrick Sowa, MD, Rami Lutfi, MD, FACS, FASMBS; St. Joseph Hospital, Chicago

Here we present a video case report of a successful laparoscopic sleeve gastrectomy after a case of severe pancreatitis requiring deviation from standard operative technique. During the index operation, upon dissection into the lesser sac, we unexpectedly encountered multiple dense and focal adhesions. Though his preoperative esophagogastroduodenoscopy was unremarkable, we were ultimately concerned about the possibility of a chronic penetrating gastric ulcer or pancreatic neoplasm. Due to diagnostic uncertainty, the procedure was electively aborted. Postoperatively, he revealed that he had been hospitalized five years prior for severe pancreatitis. Imaging reviewed from that hospitalization was concerning for peripancreatic fluid collections and possible necrosis. Repeat imaging did not demonstrate a discrete mass; however, there were adhesive fusions between the stomach and pancreas. During the second operation, the same adhesions from the index operation were encountered. Despite careful dissection, a 2 × 2 cm section of posterior gastric wall remained fused to the splenic vessels and pancreas, and was unable to be safely removed. After careful consideration of the location of the fused area, we determined that it was sufficiently lateral and would be contained within the removed specimen, and thus excluded from the neostomach of the sleeve gastrectomy. The remainder of the sleeve gastrectomy was completed in the standard fashion, and the patient recovered as expected postoperatively.

V279

Reversal of One Anastomosis Gastric Bypass for Malnutrition

Sarfaraz Baig, MS, FRCS; Belle Vue Clinic

Malnutrition is one of the concerns after a One Anastomosis Gastric Bypass(OAGB).

Most of the times it can be managed with high protein supplementation and close supervision and follow up. However, sometimes it becomes necessary to reverse the surgery to restore nutrition.

The important steps are a division of gastrojejunostomy and gastrogastrostomy.

In this video, we show our technique of reversing with special emphasis on technical points to reduce leak.

V280

Hiatal Hernia Repair + Gastric Bypass Using a Magnetic Retractor

Rafael Luengas, MD1, Gerardo Davalos, MD2, Ramon Diaz, MD 2, Daniel A Guerron, MD2; 1Hospital de La Florida - Chile, 2Duke University

The main procedures performed in bariatric surgery are the bypass, sleeve and the duodenal switch. The presence of Hiatal hernia during the preoperative patient assessment can change our decision when it comes to choosing the appropriate operation approach. We present a case in which the presence of a hiatal hernia and GERD who underwent a hiatal hernia repair plus a gastric bypass.

In hiatal hernia repair, proper exposure of the hiatus is essential. The most commonly used device for this purpose is the Nathanson which utilizes a dedicate port, however, newly developed magnetic retractors present an alternative. In this video we display the use of a magnetic retractor used to retract the liver during a hiatal hernia + gastric bypass.

The magnetic retractor provided a safe and feasible alternative for liver retraction and hiatal exposure during this procedure without the need for additional abdominal port incisions, which could potentially translate in decreased patient morbidity and increased cosmetic results.

V281

Omental Free shaped Flap Reinforcement on Anastomosis and Dissected Area (OFFROAD) Following Gastrectomy: video article

Wonho Han, Kyonglin Park, Deokhee Kim, Young-Woo Kim; National Cancer Center

The frequency of anastomotic leakage after gastrectomy is reported to be 0.9–8%. To reduce deleterious outcomes of anastomotic leakage, we devised the “Omental Free-shaped Flap Reinforcement On Anastomosis and Dissected area” procedure not only to prevent fatal complications following anastomotic leakage but also to promote vascularity of anastomoses and other expected oncological benefits. This video illustrates the surgical procedure following a totally laparoscopic distal gastrectomy. After completion of the anastomosis, the remaining omentum was mobilized upward and divided into two sections. We placed the left section of the omental flap under the anastomosis between the stomach and pancreas. Finally, we grasped and curved the tip of the section to cover the anastomosis from behind, and we placed the right section of the omental flap above the anastomosis. These two sections were approximated with clips to the anterior wall of the stomach. The patient was discharged without complications.

V282

Laparoscopic Perineal Hernia Repair with Acellular Dermal Matrix Porcine Mesh

Adel Alhaj Saleh, MD, MRCS, Amir H Aryaie, MD, FACS; Texas Tech University Health Sciences Center

  • A 65 year-old female with a history of hysterectomy for endometrial cancer and radiation in 2008.

  • Developed bladder prolapse but did not undergo suspension procedure.

  • Had urinary urgency and feeling of non empty bladder for 2–3 week for that she wanted to visit Uro/GYN clinic for evaluation.

  • One night before the clinic visit she douched and felt something coming out of her vagina.

Medical History
  • DM2

  • Charcot foot

  • HTN

  • Multiple abscesses with poor wound healing.

Surgical History
  • C/S*1, radical hysterectomy, Lt above knee amputation.

  • Open appendectomy and cholecystectomy.

  • I&D of abdominal wall abscess

  • PV exam showed omentumand bowel in the vagina

  • The vaginal opening was plugged with a bulb by the OB/GYN team.

  • CT scan of the abdomen showed dehiscence of vaginal cuff

The patient was then planned to
  • Laparoscopic Perineal Hernia Repair in lithotomy position.

Post-operative Course
  • Patient was discharged on POD #5 after making sure she could void with no issues.

  • Followed up by OBGYN in the Clinic

  • Once again referred to us because she wanted to do sleeve gastrectomy (BMI 35 kg/m2 with multiple comorbidities)

  • The patient underwent Laparoscopic Sleeve gastrectomy, 6 months after the perineal hernia repair.

  • During the procedure, pelvic floor was inspected, the ACELL mesh is holding well in place, and no abdominal content herniating to the pelvis

In Conclusion
  • Laparoscopic repair of perineal hernia with A Cell mesh is safe and feasible even if the patient had multiple abdominal procedures before.

  • A cellular matrix porcine mesh is durable and provides good support to the pelvic floor.

V283

Robotic-assisted Primary Plication of Left Hemidiaphragm Eventration

Simran K Randhawa, MD 1, Charles Bakhos, MD, FACS2; 1Albert Einstein Healthcare Network, 2Temple University Lewis Katz School of Medicine

Introduction: Hemidiaphragm eventration is a rare anomaly and can be congenital or more commonly acquired as a result of trauma, neoplasms, infection, degenerative disease, or idiopathic. Surgical treatment is indicated in the presence of symptoms and diaphragmatic plication is the surgical treatment of choice.

Methods: We present the case of a 35-year-old female who presented with shortness of breath and left upper quadrant pain. Fluoroscopy sniff test showed left hemidiaphragm paralysis with paradoxical motion and CT scan of the chest was suspicious for left hemidiaphragm eventration. Thus, a robotic assisted primary plication of the left hemidiaphragm was performed.

Results: Minimally invasive approaches to diaphragm plication for eventration include thoracoscopic, laparoscopic and robotic assisted techniques. We report our approach using robotic assistance with the da Vinci Si Surgical System, (Intuitive Surgical Inc.) to perform primary plication of left hemidiaphragm eventration. We decided to go through the abdomen to minimize any inadvertant injury to the bowel. Since the surgery, she has exhibited significant improvement in her left upper quadrant pain and dyspnea.

Conclusion: Robotic-assisted diaphragm plication for unilateral diaphragm eventration can avoid single-lung ventilation, enable excellent visualization, and allow for precise placement of plication sutures to achieve maximum plication.

V284

Laparoscopic Transabdominal Preperitoneal repair of bilateral Spigelian hernia

Mayank Roy, MD, MRCS, Vickna Balarajah, MD, MRCS, Satvinder Mudan, MD, FRCS; The London Clinic

Introduction: Spigelian hernias (SH) are rare and the anatomical landmarks can be challenging to identify at the operation. We describe a rare case of bilateral SH managed by laparoscopic transabdominal preperitoneal repair.

Methods: A 69-year-old Caucasian male presented with bilateral lower abdominal bulge and pain with increasing severity for six months. The bulge was exaggerated due to recent intentional weight loss as per the patient. Bilateral SH was confirmed on ultrasound. Appropriate consent was taken to repair the bilateral SH. Intraperitoneal access was gained through a 12-mm OptiView trocar in the left lower quadrant. A 12-mm port in the epigastric area and three 5-mm trocars were placed in the outer quadrant for proper triangulation. SH boundary was identified by anatomical landmarks (lateral edge of rectus abdominis, inferior to the arcuate line). Other important landmarks including the inferior epigastric vessels, vas deferens, the triangle of doom and triangle pain were identified. SH site was closed using an endoclose device followed by placement of a 15 × 15 proceed mesh to cover the SH site as well as the inguinal hernia. A similar repair was performed on the opposite side. Total operative time was seventy-five minutes.

Results: Patient was discharged on postoperative day 1. The patient was asymptomatic at four weeks follow up.

Conclusion: Laparoscopic transabdominal preperitoneal repair of bilateral SH can be performed with low morbidity. A laparoscopic approach can help in the identification of anatomical landmarks of SH, and the inguinal hernia sites can be covered by a mesh simultaneously.

V285

Video Presentation: Laparoscopic Morgagni Hernia Repair

Chaya Shwaartz, MD 1, Mor Aharoni, MD1, Joe Kim2, Motti Cordova, MS1, Mordechai Gutman, MD1, Danny Rosin, MD1; 1Sheba Medical Center, 2Summit Medical Group

We present a case of a laparoscopic repair of Morgagni hernia found during surgery.

This is a 82 year-old patient presented with mild abdominal discomfort. Preoperative workup suggested the diagnosis of gastric volvulus. However, during surgery, a Morgagni hernia was found. We repaired the hernia laparoscopically using an endoclose. The patient was doing well after surgery.

Diaphragmatic hernia can be acquired or congenital. Congenital diaphragmatic hernia occurs through embryonic diaphragmatic defects. Most patients present early in life. However, a subset of patients present as adults.

When this pathology found in an adult they usually have mild symptoms or are asymptomatic and the hernia discovered incidentally.

When compared to Bochdalek hernia, Morgagni hernia is rarer, smaller, located anteriorly on the right of the pt and asymptomatic.

This is relatively rare with the literature on this entity is lacking.

There are a few points to discuss regarding the repair such as the necessity of the sac removal, the closure of the defect, the use of mesh and the need for an abdominal drain.

V286

Gastric Band Erosion Over Bypass

S. Julie-Ann Lloyd, MD, PhD, Alph J Emmanuel, MD, Bestoun H Ahmed, MD, FACS, FASMBS; University of Pittsburgh Medical Center

Introduction: The estimated two-year failure rate of Roux-en-Y gastric bypass of up to 15% is primarily due to diet non-compliance versus impaired gastric restriction. The latter may result from fistula formation between the remnant and pouch or enlargement of the gastric pouch or the gastrojejunal stoma. Among operative options for weight regain, salvage gastric band placement over the enlarged pouch aims to restore a restricted pouch size and achieve durable weight loss.

Case Presentation: A 69-year-old female with history of a laparoscopic Roux-en-Y gastric bypass underwent adjustable gastric band placement as a rescue procedure for recidivism. She later presented to our emergency room with band erosion. A laparoscopic approach was utilized to carefully remove the band but she developed an adhesive, early post-operative small bowel obstruction that required adhesiolysis. On short-term follow-up, her symptoms had resolved and her weight had remained stable.

Conclusion: Laparoscopic gastric band removal is a safe and feasible technique to treat band erosion.

V287

Left Laparoscopic Standardized Adrenalectomy, Every Day Less Invasive

Jara Hernandez Gutierrez, Aurelio Francisco Aranzana Gomez, Juan S Malo Corral, Beatriz Muñoz Jimenez; CH Toledo

Introduction: After the 1st laparoscopic adrenalectomy described in 1992 (Gagner), the laparoscopic lateral transabdominal approach has proved to be the one of choice. It provides an easy anatomical orientation, the technique is similar to other traditional laparoscopic procedures and is the one described in most of the literature. On the other hand, the posterior retroperitoneoscopic adrenalectomy (PRA), described in 1995 (Waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. The advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient. Currently there is controversy about which is the approach of choice, having to take into account the learning curve necessary for the retroperitoneal approach and the reduced number of patients with adrenal pathology subsidiary of surgical management.

The objective is to demonstrate the safety and efficacy of the standardized laparoscopic approach of the left adrenal gland with 3 trocars for selected cases.

Methods and Procedures: Clinical case: 43-year-old man, resistant hypertension despite concurrent use of three antihypertensive agents of different classes, with biochemical and radiological diagnosis of left adrenal adenoma with primary hyperaldosteronism. Demonstrative video of the technical steps in a standardized way that we propose for laparoscopic left adrenalectomy only using 3 trocars.

Results: Full laparoscopic surgical approach in right lateral decubitus position: 3 trocars - lateral transabdominal approach.

Steps:
  1. 1.

    Laparoscopic liberation of the splenic flexure of the colon for the colo-spleen-pancreato-gastric en block mobilization until identification of the left pillar,

     
  2. 2.

    dissection of the medial border of the gland, identification of left renal and diaphragmatic vein, as well as the adrenal vein which is dissected and clipped,

     
  3. 3.

    dissection of the lateral edge of the adrenal gland,

     
  4. 4.

    lower pole dissection of the gland completing the resection with Ligasure®.

     

Operating time was 60 min. The patient presented a successful postoperative recovery, being discharged 24 hours after the intervention. Asymptomatic, the patient does not need antihypertensive agents after 1 year of follow-up.

Conclusion(s): Laparoscopic adrenalectomy is an effective and safe technique that associates scarce morbidity and mortality, and it has evident postoperative advantages for the patient. The standardization of the procedure allows reducing the number of trocars, maintaining the safety and effectiveness of the minimally invasive approach.

V288

Role of High Resolution Manometry in laparoscopic fundoplicaiton.

Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Shivang D Shukla, MBBS, Amol N Wagh, MS, FMAS, FIAGES, FAIS, Shekhar Jadhav, MS, Amrjeet Tandur, MS, Khushboo Kadakia, MBBS, Soumya Chatnalkar, MBBS, Priyanka Saha, MBBS, Niddhisha Sadhwani, MBBS; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

This is a Prospective randomized control trial comparing Laparoscopic Nissen’s and Toupet’s fundoplication. In our tertiary care set up, due to non feasibility of 24 hour Ph studies we have tried to establish role of HRM with upper GI scopy for diagnosing GERD and guiding us with the most appropriate treatment options.

We segregated patients into two groups, one with ineffective esophageal motility and one with normal motility. Patients in either group were randomized into those who will undergo Laparoscopic Toupet’s and Nissen’s repair.

Mean LES pressures were recorded in both the groups. Incidence of dysphagia was documented in either group at 6 months and after 2 years

Our results showed that Toupet’s fundoplication was better than Nissen’s in both the groups.

This study highlights the role of manometry in tailoring appropriate procedure for GERD. It also delineates the role of HRM in diagnosing GERD in a tertiary set up where 24 hr ph study is not feasible due to many factors.

V290

Laparoscopic Repair of Interparietal Abdominal Wall Hernias

Christopher L Kalmar, MD, MBA, Curtis E Bower, MD, FACS; Virginia Tech Carilion

Background: Interparietal hernias are a rare form of abdominal defect where intraabdominal contents protrude between layers of the abdominal wall. Incidence is estimated to be about 0.1 to 1.6% and more often seen in adult males. There is limited experience using laparoscopic technique for repairing substantially large interparietal hernias.

Methods: An 84-year-old female presented for evaluation of left upper abdominal quadrant bulge, which had been present after left flank incision for lumbar spine surgery. CT scan demonstrated an intact external oblique muscle, but the internal oblique and transversus abdominis on the left side were detached from the linea semilunaris with a 10 cm defect. A 53-year-old female presented for evaluation of right flank bulge after right nephrectomy resulting in an interparietal hernia with a 13 cm defect.

In both cases, the peritoneum was opened to allow better exposure of the muscle. We used a #1 barbed synthetic absorbable monofilament suture (StrataFix™ PDS™, Ethicon, Somerville, NJ) to approximate the linea semilunaris back to the internal oblique running the suture in cranial direction. Thereafter, we reversed the direction to return running the suture in caudal direction prior to cutting the stitch. Next, attention was turned to mesh reinforcement of the incisional hernia. We placed a 15 × 10 cm monofilament macroporous composite mesh (Symbotex™, Covidien Medtronic, Mansfield, MA) in underlay fashion securing it to the abdominal wall using a laparoscopic absorbable tack fixation device (AbsorbaTack™, Covidien Medtronic, Mansfield, MA).

Results: The patients did well postoperatively and were both discharged on the first postoperative day. At one-month and two-month postoperative follow-up, our patients continued to do well with resolution of abdominal wall discomfort and resolution of abdominal wall hernias.

Conclusion: Our experience demonstrates the largest interparietal hernias treated entirely with laparoscopic repair. Barbed suture helped maintain suture tension between bites keeping distantly opposing aspects of the muscular abdominal wall securely approximated. In addition to primary suture repair, mesh reinforcement helped offload tension. Moreover, reducing the insufflation pressure during the approximation of the abdominal wall defect was beneficial in ensuring adequate tissue approximation of substantially large abdominal wall defects. This technique successfully resolved these large interparietal hernias entirely with laparoscopic approach helping patients achieve resolution of their symptoms and abdominal wall irregularity, as well as achieve discharge on the first postoperative day without complication.

V291

Thoracolaparoscopic Oesophagectomy for end stage Achalasia

S Velmurugan, HOD of GI and Lap Surgery, R Archana, B Kasi Viswanath; kauvery hospital, Trichy, India

62 year old male presented with dysphagia, cough, loss of weight and appetite. There was history of recurrent pneumonitis due to repeated aspiration. He was diagnosed to have achalasia cardia few years before this presentation. He had already undergone laparoscopic Heller’s Cardiomyotomy, which relieved his dysphagia for few years. Then he had endoscopic balloon dilatation for recurrent achalasia, which helped him only temporarily. His endoscopy and imaging showed end stage achalasia with evidence of recurrent aspiration.

After informed consent, thoraco - laparoscopic oesophagectomy was performed. Intra operative finding was mega oesophagus measuring about 8 cm diameter filled with food residue. There were lung adhesions in right hemithorax.

Procedure:

THORAX - Prone position. Single lung ventilation. Two 10 mm ports and two 5 mm ports used. Lung adhesions carefully released. Azygous vein ligated. Inferior pulmonary ligament divided. Entire length of intrathoracic oesophagus mobilized with Harmonic scalpel. Haemostasis checked. Chest drain inserted.

ABDOMEN - One 10–12 mm port, one 10 mm port and three 5 mm ports used. Adhesions from previous surgery released. Laparoscopic mobilisation of stomach based on right gastro-epiploic and right gastric vessels performed.. Hiatal dissection done and lower oesophagus freed. Left gastric vessels ligated and divided. Mini upper midline incision made. Gastric conduit fashioned with stapler. Pyloromyotomy done.

NECK - Oblique incision. Deep fascia opened. Muscles retracted. Oesophagus slung and oesophagectomy done. Gastric conduit delivered into neck. Oesophago-gastric (side to side) anastomosis was done with stapler. Stapler entry site sutured in two layers with 3-0 PDS. Ryles tube passed through into stomach.

Feeding jejunostomy done.

On 8th postoperative day, he aspirated. He needed non invasive respiratory support. Later tracheostomy was performed. He slowly recovered from his aspiration pneumonitis and tracheostomy tube was removed. Further recovery was uneventful. On follow up, there was no dysphagia and he gained weight.

V292

A Robotic Tour of the Foregut: Hiatal Hernia Repair, Partial Gastrectomy, Pyloroplasty, and Cholecystectomy

Benjamin J Flink, MD, MPH, Priya Rajdev, MD, Scott Davis, MD, FACS, Jamil L Stetler, MD, FACS, Edward Lin, DO, MBA, FACS, Ankit D Patel, MD, FACS; Emory University

Minimally invasive surgery in the foregut can be challenging when planning port placement for more than one operative target, i.e. the hiatus and the biliary tree. Robotic surgery, which allows seven degrees of freedom, provides increased versatility and improved ability to address multiple sites from the same ports. In this video, we present a robotic gastric wedge resection for a GIST tumor, hiatal hernia repair with Toupet fundoplication, pyloroplasty and cholecystectomy. All three operative sites in the abdomen were completed with five ports and did not require re-docking of the robot, saving significant time while maintaining a safe and comfortable operative environment.

V293

Laparoscopic radical left hemicolectomy: a bursa omentalis approach

Wei Wang, Wenjun Xiong, Jin Wan, Xiaofeng Zhu; Guangdong Provincial Hospital of Chinese Medicine

In several classic trials comparing laparoscopic versus open colectomy, splenic flexure cancer was excluded. One of the most important reasons was the technical difficulty of laparoscopic splenic flexure mobilization. Separating left Toldt’s fascia was prior to entering the bursa omentalis in conventional laparoscopic left hemicoletomy. However, in this approach, identifying pancreas is very demanding, especially for fatty patients, and it is easy to enter the retro-pancreatic space for unexperienced surgeons. Herein, we introduce a bursa omentalis approach for laparoscopic radical left hemicoletomy to facilitate splenic flexure mobilization and explore its safety and feasibility.

Firstly, the left part of gastrocolic ligament was dissected and the bursa omentalis was entered. It was easy to identify the middle colic vessel and inferior mesenteric vein. The anterior lobe of the mesentery of transverse colon was dissected at the inferior border of pancreas from right to left and a piece of gauze was placed at the inferior border of pancreas for introduction.

Secondly, the left Toldt’s fascia was dissected at the level of the sacral promontory. The left Toldt’s space was expanded cephalad and the pancreas was identified clearly with the introduction of the gauze. Meanwhile, the inferior mesenteric artery and vein were ligated at root. It was easy to combine the left Toldt’s space and bursa omentalis.

Thirdly, the lateral attachments of the descending colon were completely mobilized and an extracorporeal side-to-side anastomosis was performed with an umbilical incision.

V294

Laparoscopic reduction of jejunojejunostomy intussusception after Roux-en-Y gastric bypass

Rana M Higgins, MD, Jon C Gould, MD, Tammy L Kindel, MD, PhD; Medical College of Wisconsin

A 36 year-old morbidly obese female underwent a laparoscopic Roux-en-Y gastric bypass. Her BMI at the time of surgery was 53 kg/m2. She continued smoking and subsequently developed a marginal ulcer, for which she had a revisional gastrojejunostomy performed with remnant gastrostomy tube placement 1.5 years after her initial operation. She continued to struggle with recurrent marginal ulcers and chronic pain. She presented to the Emergency Department 2 years after her initial gastric bypass with 1 day of worsening abdominal pain, nausea and vomiting. A CT abdomen was performed demonstrating obstruction at her jejunojejunostomy and concern for an intussusception and internal hernia. She was taken urgently to the operating room for laparoscopic exploration. Intraoperatively, a small bowel intussusception was identified of the common channel limb retrograde into the jejunojejunostomy. With slow and gradual tension, the intussuscepted small bowel was able to be reduced, with a significant amount of edema released. Once the intussusception had been reduced, the bowel was inspected and noted to be viable. The jejunojejunostomy was identified and an enteropexy was performed of the common channel to the biliopancreatic limb. Post-operatively the patient recovered well and was discharged home on post-operative day 3, no longer requiring narcotic pain medications.

V295

Minimal invasive drainage of a large a large pancreatic pseudocyst

Ionut Bogdan I Diaconescu, Matei Razvan Bratu, Dragos Ene, Mircea Beuran; Carol Davila University of Medicine and Pharmacy

Introduction: Laparoscopic cystogastrostomy is an suitable procedure for the drainage of pancreatic pseudocysts if the cysts is present in the lesser sac (retro-gastric).

Methods: We present 2 consecutive cases where transmural drainage was tried, but for two cases it failed, because the cyst wall was thick and the cyst had completely compressed the stomach, making endoscopic manipulation difficult inside the stomach.

Results: Laparoscopic drainage was a simple solution to the problems in managing a huge pancreatic pseudocyst of 17 cm × 18 cm in a 57 years old male with a history of acute pancreatitis. Ultrasound and computed tomography revealed showed a walled off cystic collection that pushed the stomach superiorly. The cyst was exposed by dissecting the lesser omentum and found to have no adhesion to the surrounding tissues. Anastomosis was performed using an endoscopic linear stapler via small cystotomy and gastrotomy openings on the lesser curvature, which were then sutured laparoscopically. The postoperative course was uneventful. Laparoscopic cholecystectomy was done in 6 weeks later after the drainage procedure.

Conclusion: Laparoscopic surgery is recommended as a safe, reliable, and minimally invasive treatment for managing pancreatic pseudocyst.

V296

Retro-Roux Biliopancreatic Limb: A Case Report and Technique For Repair

Joseph Greene, MD, MBA, Hamid Pourshojae, DO, Nain Rajev, Amir Moazzez, MD; Inova Fair Oaks Hospital

Through this case we describe the importance of jejunojejunostomy laterality relative to the Petersen’s defect of the Roux alimentary limb during laparoscopic Roux-en-Y gastric bypass surgery. When the jejunojejunostomy is constructed on the right side with the biliopancreatic limb entering from the right side, the biliopancreatic limb is brought through the Petersen’s defect, creating a permanent internal hernia and a nidus for herniation. When the jejunojejunostomy is constructed correctly on the left side with the biliopancreatic limb entering from the patient’s left side, all defects can be closed satisfactorily.

V297

Revision of Dor to Nissen Fundoplication with Collis Gastroplasty and Placement of Bioabsorbable Mesh

Ellen Wicker, DO, Evan Liggett, MD, Carlos Lodeiro, BS, Benjamin Clapp, MD; Texas Tech HSC Paul Foster School of Medicine

Introduction: Recurrence after fundoplications is a common surgical problem. Revision of foregut surgery can be very difficult and requires a clear understanding of the previous operation. Currently used fundoplications include the Nissen, Dor and Belsey fundoplications among others. For the surgeon faced with revising a fundoplication, a working knowledge of all of the previous operations is essential. Esophageal lengthening procedures can also be necessary during these revisions.

Description of Video: This video is a case report of a 60-year-old female who underwent a Dor fundoplication 10 years prior. She had a history of GERD, and her fundoplication was complicated by esophageal perforation by the bougie. The surgeon repaired the esophageal perforation but performed a Dor to reinforce this repair. She subsequently had a recurrence of her GERD and hiatal hernia. Repeat endoscopy and upper GI showed a paraesophageal hernia with a partially intact wrap. The video shows the operative approach of converting the Dor to a Nissen fundoplication with an esophageal lengthening procedure and repair of the hiatal hernia with a bio-absorbable mesh. The video highlights some of the technical pearls of this operation including takedown of the previous fundoplication, exposure of both diaphragmatic crura, mediastinal dissection and the importance of intra-operative endoscopy.

Discussion: Revision of foregut surgery is technically challenging. These cases can be approached with a laparoscopic technique by surgeons with an appropriate skill level. It is important that the surgeon reads the previous operative notes, reviews preoperative studies such as upper GIs and should personally perform pre-operative endoscopy. A working knowledge of the common fundoplication techniques and the anatomy of the foregut is essential.

Conclusions: Revisions of fundoplications are technically challenging and complex cases. These operations can be done safely laparoscopically and the surgeon should consider using a bio-absorbable mesh to reinforce their repair.

V298

Laparoscopic Robotic-Assisted Removal of Hiatal Mesh for Postoperative Severe Dysphagia

Enrique F Elli, MD, FACS, Tamara Diaz Vico, MD; Mayo Clinic Florida

We present the case of a 47 years-old female with history of kidney transplantation, who underwent a paraesophageal hernia repair with mesh in 2009. The patient complained about progressive dysphagia and heartburn for the last months. Preoperative studies were performed in order to reach a final diagnosis. The upper GI showed an image compatible with achalasia. An upper endoscopy showed esophagitis, a stricture and stenosis of the distal esophagus. The manometry was not conclusive, and the patient failed to endoscopic dilation. Finally, decision was made to undergo an intraoperative evaluation.

Two 12-mm and three 5-mm robotic trocars were placed in a wide “v”. The procedure started with a diagnostic laparoscopy, showing adhesions in between the stomach, the liver, and the previous mesh. Using monopolar hook, adhesions were carefully taken down. Mesh was identified constricting the esophagus at the level of the hiatus. This dense material was attached to the distal esophagus too at the level of the esophagogastric junction. Also, the stomach was completely detached from the liver and from the previous mesh. The mesh was detached completely from the hiatus. Dissection continued posteriorly to the esophagus and a Penrose drain was placed around. The robotic third arm was used for retraction and exposure. Using monopolar scissors, the esophagus was dissected from the mesh inside the mediastinum. Then, an intraoperative endoscopy was performed, showing that the restriction at the distal esophagus was resolved and the previous fundoplication was intact.

Once the mesh was removed and the stenosis of the distal esophagus was resolved, the pillars of the hiatus were approximated with interrupted stitches of 2-0 Ethibond to restored the anatomy.

The operative room time was 120 minutes, with no intraoperative complications. Patient was asymptomatic after the surgery, with good oral tolerance. She was discharged on postoperative day 3, and no evidence of recurrence was noticed.

V299

Laparoscopic Bile Duct Excision

Ammiel Arra, Dr, N Bascombe, Dr, M Bartholomew, Dr, D Dan, Prof; San Fernando General Hospital

Objective: Due to the risk of malignancy, the established management of choledochal cysts mandates bile duct excision and biliary reconstruction. While the reconstructive procedure of choice for most surgeons has traditionally been hepatico-jejunostomy, this may not be feasible in selected cases due to immobility or inadequacy of the jejunum. Hepatico-duodenostomy, while traditionally thought to be associated with a higher risk of complications, may be the only alternative for such patients. The following case will outline the management of a 32-year-old woman with short bowel syndrome, who was diagnosed with choledocholithiasis and a type 1 choledochal cyst.

Method and Materials: As a child, our patient suffered midgut volvulus secondary to malrotation which resulted in extensive bowel resection. She was left with 100 cm of small bowel anastamosed to the transverse colon and subsequently developed short bowel syndrome. She compensated very well but developed cholelithiasis and extensive choledocholithiasis, which was further complicated by recurrent bouts of cholangitis. Imaging of her biliary tree confirmed common duct stones extending into the branched hepatic ducts, as well as a fusiform dilatation of the common bile duct, that appeared consistent with a type 1 choledochal cyst. Laparoscopic clearance of the biliary tree and excision of the cyst with reconstruction using a hepatico-duodenostomy was planned.

Results: The patient underwent successful laparoscopic Cholecystectomy, CBD clearance with excision of the bile duct and reconstruction with hepatico-duodenostomy. A short video is presented to demonstrate the technique used. The procedure took 4 hours and she was discharged on day 3. The patient had an uneventful recovery and remains asymptomatic on subsequent follow-up. Histology is consistent with a markedly dilated bile duct rather than choledochal cysts.

Conclusions: This case illustrates the dilemma of diagnosis and treatment of choledochal cysts in a patient with short bowel syndrome and the feasibility of laparoscopic bile duct excision and reconstruction, while demonstrating that hepaticoduodenostomy may be a safe alternative in selected cases with limited material for conduit.

V300

Robot-Assisted Laparoscopic Right Hepatectomy

Subhashini Ayloo, MD, MPH, Jacob Schwartzman, MD; Rutgers, New Jersey Medical School

Objective: To demonstrate the safety and feasibility of robot-assisted right hepatectomy in a septuagenarian without the implementation of Pringle maneuver.

Materials & Methods: A 72 year old man presents with right upper quadrant abdominal pain. Diagnostic imaging showed a large complex mass. Characteristics are consistent with hemangioma but primary liver malignancy cannot be ruled out secondary to multiple nodules within this large mass.

This video showcases the technical details of a minimal invasive approach to right hepatectomy. A diagnostic laparoscopy is performed, showing significant adhesions to the lesion and the complex, nodular, multi-colored characteristics of the lesion. A cholecystectomy is performed, followed by marking the resection line from gallbladder fossa to right hepatic vein. A stay suture is placed in the inferior portion of segment 4 to retract the left lobe laterally. Intraparenchymal dissection is performed using a combination of monopolar scissors, bipolar cautery and staplers towards hepatic vein branches. Any branches of the hilar blood vessels are suture ligated when encountered. Parenchymal transection is the most time consuming part of the operation. The specimen is extracted via a Pfannensteil incision.

Conclusions: Robot-assisted right hepatectomy in a septuagenarian is safe and feasible. The Da Vinci system provides a stable platform with 3-D visualization and improved ergonomics, which facilitate suture ligation at difficult angles of blood vessels as they are encountered and does not require Pringle maneuver.

Educational/Technical Points: The camera is positioned right mid-abdomen, with the left and right arms of the surgeon on either side. The robotic fourth arm is placed in a left lateral position, and a first assistant port is placed inferomedial to the surgeon’s left arm. The 4th arm of the robot has a multifunctional purpose in retracting the left lobe to keep the resection plane in alignment to camera. The degrees of freedom afforded by the robotic system allow for suturing at difficult angles as the blood vessels are encountered and the obviate need for Pringle maneuver.

V301

Laparoscopic Whipple in a South American Public Hospital

Ramon Diaz, MD 1, Gerardo Davalos, MD1, Daniel A Guerron, MD1, Andres Marambio, MD2, Jose Galindo2; 1Duke University, 2Hospital La Florida - Chile

Whipple procedures have been historically considered one of the most technically demanding operations in surgery. The introduction of the laparoscopic Whipple represents an even greater challenge, that only highly trained and selected centers in the United States have been able to master.

We present a case of a Laparoscopic Whipple performed in a patient with a pancreatic tumor in a South American Public hospital, where the opportunity to perform this type of advanced procedures is limited. This video illustrates the feasibility of performing this highly technically challenging procedure in a low resource environment public hospital.

V302

Robotic gastric band removal and gastrocolic fistula repair

Maher Ghanem, MD, FACS, Ghaith Al-Qudah, MD, Samuel Shaheen, MD, FACS; Central Michigan University

Purpose/Value: Robotic surgery is a feasible and safe option for a wide variety of minimally invasive surgical interventions that would otherwise require an extensive open approach. This case is an example of the diversity of techniques that can be done robotically.

Case Presentation: A 42 year-old male presented with a history of morbid obesity, status post laparoscopic gastric band insertion eight years prior to presentation. He complained from abdominal pain, and his work-up including endoscopy and colonoscopy revealed that the gastric band was eroding into the stomach and colon.

Procedure: After being counseled on the importance of surgical repair, the patient agreed to the procedure and was taken to the operating room. Intra-operatively, the gastric band was found to be eroding into three hollow organs; stomach, small bowel, and colon. A robotic gastric band removal with repair of the stomach, with open partial small bowel resection and colon repair were performed. The patient recovered well post-operatively and was eventually started on clear liquids on the ninth post-operative day.

V303

Robotic retrorectus sugarbaker parastomal hernia repair

Anna R Spivak, DO, Jonathan Y Gefen, MD; Lankenau Medical Center

We present the case of a 71 year old female with a recurrent parastomal hernia that had failed two prior anterior repairs. At the site of her left lower quadrant end colostomy, there was a 4 cm defect containing a massive amount of unobstructed small bowel. We repaired the hernia using a hybrid Sugarbaker/transversus abdominis release (TAR) with a robotic approach. This combined the Sugarbaker method of stoma lateralization and subfascial mesh placement, with the component separation and extraperitoneal mesh positioning of the TAR procedure. We believe this provides a combination of durability and safety while maintaining a minimally invasive approach.

The DaVinci Xi platform was used. One 12-mm port, two 8-mm ports, and one 5-mm port were placed in the right side of the abdomen. Midline adhesions were lysed, and the left lower quadrant parastomal hernia contents were reduced. The medial aspect of the left posterior rectus fascia was incised vertically. The retrorectus space was developed with blunt dissection and electrocautery. A transversus abdominis release was performed medial to the perforating vessels, and the preperitoneal plane was developed. By approaching the colostomy from above and below, the preperitoneal plane was opened circumferentially around the colostomy.

The posterior layer of the hernia defect – the posterior rectus fascia with parietal peritoneum – was closed with sutures medial to the colostomy. The anterior layer was separately closed on the medial side of the colostomy. This lateralized the descending colon and stoma conduit. Next, a laparoscopic self-fixating mesh was placed on the anterior layer. A small notch was created on the lateral side of the mesh to accommodate the lateralized colostomy and extend laterally superior and inferior to the stoma. A patch of biologic mesh was placed between the colostomy and self-fixating mesh to prevent mesh adherence to the colon. After satisfactory placement of the mesh, the initial incision in the posterior rectus fascia was closed in the midline. This repair achieved placement of the mesh outside the peritoneal cavity, closure of the hernia defect medial to the colostomy, and lateralization of the colostomy. Her recovery was uneventful, and she was discharged home on postoperative day 3. At two months follow-up, there is no sign of recurrence or discomfort.

V304

Robotic Subtotal Colectomy

Cory Banaschak, MD, Rima Ahmad, MD, Kirpal Singh, MD; St. Vincent’s Hospital, Indianapolis

Presented here is a case of a robotic subtotal colectomy performed with the DaVinci Xi robotic system. Due to the upgraded technology involved with the Xi, the robot can be manipulated to work in multiple quadrants of the abdomen, at varying distance from the ports. In our current case, it allowed us to complete a subtotal colectomy using the same port configuration and re-docking the system just once to switch from the left abdomen to the right. The dissection was completed systematically and without difficulty in manipulating the robotic arms.

V305

Massive Splenomegaly:Standardized Laparoscopic Approach

Aurelio Francisco Aranzana Gomez, Jara Hernandez Gutierrez, MD, Juan Malo Corral, Soledad Buitrago Sivianes; Hospital Virgen De La Salud, Toledo

Introduction: Currently, laparoscopic splenectomy is considered the technique of choice for benign hematological diseases in which exeresis of the spleen is indicated, this type of approach being controversial for the malignant diseases that affect this organ, since it is convenient to extract the piece surgical procedure for its AP study and usually involves large lesions.

Objective: To demonstrate the safety and efficacy of the laparoscopic approach in massive splenomegaly.

Material and Method: Clinical case of a young patient, studied by hematology due to massive splenomegaly (spleen of more than 20 cm). It provides iconography and complementary explorations of interest.

Results: Semi-lateral and complete laparoscopic approach, 4 trocars, splenomegaly of more than 20 cm, opening of the gastroesplenic ligament, section (EndoGIA) of the splenic artery, to decrease spleen size, identification of the pancreatic tail, mechanical section of the splenic vein, mobilization and complete extraction of the part after enlarging the lateral trocar orifice, drainage placement, good postoperative course, discharge on the 3rd day. ECODOPPLER control the week that demonstrates portal thrombosis that requires anticoagulation by hematology. Definitive AP: Splenic low grade B lymphoma. Asymptomatic and with resolution of portal thrombosis after 2 years of follow-up.

Conclusions: In selected patients and experienced teams, the size of the spleen is not a contraindication for the laparoscopic approach with the advantages already known for this type of technique. We recommend performing a follow-up echo-doppler to rule out laparoscopic post-splenectomy portal thrombosis, given the proven incidence of this complication when, in addition, there are associated risk factors.

V306

Robotic total abdominal colectomy with ileorectal anastomosis

William Steinhardt, MD, Ty A Bowman, MS, Heidi Lentz, MS, Henry J Lujan, MD, FACS, FASCRS; Jackson South Community Hospital

This video demonstrates a robotic total abdominal colectomy with ileorectal anastomosis. The indication for the procedure was attenuated familial adenomatous polyposis in a 75-year-old male. Port placement is shown and the reasoning for the orientation and operative approach are discussed. 4 robotic and 2 assistant ports are used to complete the procedure. The video describes a counter clockwise dissection approach. Identification of the distal margin, mobilization, identification of the ureter, devascularization and transection near the rectosigmoid junction are shown. Timing of docking, undocking, and redocking the robot with table repositioning are discussed. Approach to the splenic and hepatic flexures is demonstrated. The right lower quadrant incision used for the robotic stapler port is extended to 5 cm for specimen extraction. Intracorporeal anastomosis is performed with a 25 circular stapler and reinforced with a 3.0 barbed suture using the robot. Operative time was 312 minutes. The patient was discharged on postoperative day 2 and was doing well without complications at 6 months follow up.

V307

Laparoscopic curettage and aspiration technique in right hemicolectomy with complete mesocolic excision

Wei Wang; Guangdong Provincial Hospital of Chinese Medicine

Here, we introduce laparoscopic curettage and aspiration technique in right hemicolectomy with complete mesocolic excision.

Firstly, the mesocolon between the ileocolic pedicle and superior mesenteric vein was identified. The mesocolon and the peritoneum along the superior mesenteric vein was dissected. The superior mesenteric vein was exposed. The right Toldt’s space and the pancreatic duodenal anterior space were separated with complete mesocolic excision. Then the ileocolic vessels (ICVs), right colic vessels (RCVs), Henle’s trunk and its branches and the middle colic vessels (MCVs) were exposed. The ICVs, RCVs, right branch of MCVs were ligated at root.

Secondly, the gastrocolic omentum was dissected for full mobilization of the mesocolon containing 10 cm of normal colon distal to the lesion. And the lateral attachments of the ascending colon was also separated.

Finally, the peritoneum between the mesentery and retroperitoneum was cut. The right colon was completely mobilized.

V308

Robotic Central Pancreatectomy with Distal Roux-en-Y Pancreaticojejunostomy

Kathryn Harris, MD, Jordan Wilkerson, MD, Kirpal Singh, MD; St. Vincent Hospital

This is a video abstract demonstrating an attempted robotic pancreatic enucleation of a pancreatic neuroendocine tumor utilizing intra-operative ultrasound that, ultimately, required central pancreatectomy with distal Roux-en-Y pancreaticojejunostomy. The decision was made to perform the central pancreatectomy after an inability to adequately resect the mass via enucleation confirmed by intra-operative surgical pathology.

V309

Lumbar Hernia Repair: A Transabdominal Laparoscopic Approach with Extraperitoneal Mesh Placement

Robert A Grossman, MD, Daniel Bergholz, BA; Mount Sinai Medical Center

Introduction: Lumbar hernias are rare abdominal wall defects. Fewer than 400 cases have been reported in the literature, and account for 2% of all abdominal wall hernias. Lumbar hernias are divided into Grynfelt-lesshaft or Petit hernias. The former are hernia defects through the superior lumbar triangle, while the latter are defects of the inferior lumbar triangle. Primary lumbar hernias are further subdivided into congenital and acquired hernias that can be classified as either primary or secondary. Secondary hernias occur after previous flank surgeries, iatrogenic muscular disruption, infection, or trauma.

Method: We review a rare presentation of metachronous symptomatic bilateral secondary acquired lumbar hernia following spine surgery. A successful laparoscopic trans-abdominal lumbar hernia repair with extra peritoneal mesh placement was performed, with resolution of the hernia symptoms.

Conclusion: Acquired lumbar hernias are extremely rare; most general surgeons may not encounter a case in their careers. Bilateral lumbar hernia following spinal fusion surgery has not been well described in the literature, and as such there is no clear guideline for management. Different surgical techniques to repair lumbar hernias have been described. We present a successful repair of a right-sided Grynfelt hernia using trans-abdominal laparoscopic retroperitoneal mesh placement.

V310

Transanal Endoscopic Microsurgery – Excision of a Giant Villous Adenoma

Camylle St-Laurent, MD, FRCSC, MSHc, Francois Letarte, MD, FRCSC, MHSC; CHU de Quebec

This video presentation is about a transanal endoscopic microsurgery used for the excision of a giant villous adenoma. A 68 years old woman, with no previous medical history, presented in the emergency room with complaints of fatigue and dizziness. The blood tests revealed hyponatremia, severe hypokalemia and an acute kidney failure. Multiple investigations were conducted which initially led to the conclusion of a renal tubulopathy. A thorough questionnaire later revealed the presence of mucoid discharge per rectum that had been occurring for a period of few months. The following digital rectal examination showed the presence of a large soft mass. Hence, a Mckittrick-Wheelock syndrome was suspected.

A colonoscopy was then performed and a large circumferential villous adenoma involving the entire rectum was confirmed, extending from the dentate line up to the rectosigmoid junction. The lesion appeared benign and biopsies confirmed tubulovillous adenoma. The patient was then referred to the colorectal surgical team. After discussion, transanal excision using TEM was scheduled but the patient was also consented for the possibility of conversion to a transabdominal approach with low anterior resection and coloanal anastomosis with loop ileostomy.

Submucosal dissection was used rather than a full thickness excision in order to avoid the necessity to close the huge deficit. Infiltration of the submucosal plane with a normal saline solution with epinephrine was used to elevate the lesion from the muscular layer and facilitate dissection. Because of its size, fragmentation of the specimen was necessary to maintain adequate visualization and allow complete removal. By the end, the tumor was fully resected with a small area of mesorectal transgression, but an overall satisfying result.

Post-operatively, the patient recovered fully with normal anorectal function and was discharged 7 days later due to atrial fibrillation. She presented to the emergency six weeks later with symptoms of partial obstruction secondary to small focal area of rectal stricture. Three endoscopic ballon dilations were easily performed over two months. Five months later, she is free of any symptoms with normal gastrointestinal function.

V311

Laparoscopic three ports CBD exploration with primary closure and biliary fistula resection in a hostile abdomen after a failed ERCP

Daniel Gomez, MD, FACS 1, Luis F Cabrera, General Surgeon2, Andrez Mendoza, General Surgeon2, Ricardo Villareal2, Mauricio Pedraza2, Jean Pulido2, Eric Vinck2, Sebastian Sanchez2; 1CPO, 2Bosque University

Introduction: The laparoscopic biliary tract exploration it’s a challenging procedure by itself, but in patients with a hostile abdomen due to multiple adhesions secondary to previous surgeries, increase the risk of injuring the neighboring organs, and difficult the exposure of the operative field avoiding the critical identification of bile duct structures, making this an even more complex case scenario.

Objectives: To show that laparoscopic bile duct exploration plus the resection of a biliary fistula in patients with previous surgeries is feasible in expert hands, with favorable results for the patient.

Materials: This is a case of a patient with multiple previous open abdominal surgeries which presented with chodocholitiasis that couldn´t be resolve by ERCP, deciding to carried a laparoscopic three ports approach, beginning with a Palmer port on the right flank, performing a wide release of postoperative adhesions till achieving a better surgical field placing 2 additional working ports, proceeding with the dissection and resection of a duodenal gallbladder fistula using a linear stapler and subsequently to a laparoscopic biliary tract exploration with multiple giant stones extraction, primary closure of the CBD plus cholecystectomy.

Results: Surgical time of 155 minutes, intraoperative bleeding of 15 cc, oral intake at POD 1, no re-interventions, no postoperative biliary leak, no need for intensive care unit, no mortality and a 5-day hospital stay.

Conclusions: The most complex step in the exploration of the laparoscopic bile duct in patients with previous abdominal surgery is the creation of the pneumoperitoneum and the extensive release of adhesions, in order to obtain an adequate operative field, in addition to a primary closure of the common bile duct, which has shown to have fewer complications and costs when compared to the T-tube, since the laparoscopic approach in this special type of patients has not been shown to increase bleeding or perioperative complications in expert hands.

V312

Endoscopic Vacuum Assisted Closure for Management of Leak Post Collis-Nissen

Stephanie Kerlakian, MD, Amy Murphy, DO, Katherine Meister, MD, Kevin Tymitz; Trihealth

This is a case report discussing Endoscopic Vacuum Assisted Closure (E-VAC) management of a patient who developed a leak after laparoscopic hiatal hernia repair with collis gastroplasty and nissen fundoplication. This case discusses the events leading up to her surgery, her postoperative course and presentation and management of her complication. This video discusses management of her leak using E-VAC and its effectiveness.

V313

Robotic-Assisted Recurrent Paraesophageal Hernia Repair with Mesh and Nissen Fundoplication

Enrique F Elli, MD, FACS, Tamara Diaz Vico, MD; Mayo Clinic Florida

We report a 25 years-old patient, with history of GERD and previous paraesophageal hernia repair with a biological mesh in 2012. The patient came to our clinic complaining of dysphagia and postprandial epigastric pain. Preoperative studies were performed, including a fluoroscopic contrast study that showed a recurrence of the paraesophageal hernia. Patient was selected to undergo a robotic repair of the recurrence.

Two 12-mm and three 5-mm robotic trocars were placed in a wide “v”. The procedure started with a diagnostic laparoscopy, showing hiatal herniation and tackers placed over the previous biological mesh. Using monopolar hook, right crus was dissected. The stitches from previous cruroplasty were also seen and cut. The tackers were removed from the hiatus, and also from the posterior side of the esophagus. Dissection was carried out posterior to the esophagus, and continued around the left crus. Through a posterior window, a Penrose drain was placed around the esophagus for retraction and exposure. Once the dissection in the mediastinum was finished, the pillars were approximated with interrupted stitches of 2-0 Ethibond. An anterior interrupted stitch was placed to restored the anatomy. A biological mesh was emplaced to reinforce the hiatus. The mesh was stitched to the hiatus with multiple absorbable sutures. The robot allows for precise placement of sutures. Lastly, a Nissen fundoplication was performed using interrupted absorbable sutures. Using a robotic instrument, the wrap was checked to confirm a floppy Nissen.

The operative room time was 135 minutes. No intraoperative complications occurred. The postoperative course was uneventful and the patient was discharge on postoperative day 1.

V314

Laparoscopic subtotal gastrectomy with Roux en Y reconstruction for gastro antral vascular ectasia

Daanish Kazi, Leena Khatan; UH Cleveland Medical Center

Gastro antral vascular ectasia (GAVE) or watermelon stomach (WS) is a rare and occult cause of upper gastrointestinal blood loss or anemia. Patients chronically require blood transfusion and hae associated morbidity and debility. It has a very specific histopathologic findings, the pathogenesis is unknown but is associated with several disease process. Treatment modalities include medical, endoscopic and surgical alternative. Surgery with goal of early permanent cure and improvement of quality of life along with treatment of patients GERD, hypertension, and morbid obesity was achieved. Presented is a case for early surgery intervention with subtotal gastrectomy and Roux en Y reconstruction

V315

Laparoscopic Resection of Common Bile Duct Cyst with Advanced Biliary Reconstruction

Daniel Gomez, MD, FACS 1, Luis F Cabrera, MD, General Surgeon2, Andres Mendoza, MD, General Surgeon2, Ricardo Villarreal, MD2, Mauricio Pedraza2, Jean Pulido2, Eric E Vinck, MD2, Sebastian Sanchez2; 1CPO, 2Bosque University

Introduction: Common bile duct cysts are infrequent pathologic anomalies of the biliary system. When present they cause significant signs and symptoms ranging from abdominal pain to cholangitis. All CBD cyst are potentially malignant with a risk of developing malignancy of up to 30%, therefore surgical resection is imperative in the treatment arsenal especially type I and IV.

Objective: Describe a minimally invasive approach to common bile duct cyst and detailing aspects of cystic resections in laparoscopic surgery.

Methods: We present a case of a 35-year old female patient presenting with a type IA CBD cyst. The patient is taken to a laparoscopic cyst resection along with a biliary reconstruction. This approach involved broad dissection around the CBD exposing all biliary structures as well as the cyst. After removing damaged and inflamed tissue and providing an adequate view of the entire cyst, resection was performed using a linear mechanical suture for the CBD and sharp dissection to cut the hepatic duct. A biliary reconstruction is performed using a Roux in Y technique, and the gallbladder is removed along with the cyst in a block extraction style.

Results: Surgery time was 146 minutes, intra-operative bleeding was 15 cc and total hospital stay was 4 days. The patient had a complete laparoscopic procedure with no need for ICU admission, no bile leaks were reported or other complications in the postoperative days. Oral intake at post operatory day 1. Five-year follow-up showed no signs of biliary strictures.

Conclusions: CBD cyst are complicated pathologies with a high malignancy risk and laparoscopic approach is becoming a standard of treatment for type I and IV cysts. The technicalities of laparoscopic bile duct cystic surgery put a great demand on the surgeon, thus laparoscopic resections should always be considered if the equipment is available and inexperienced hands. Minimally invasive approaches can be a safe and effective treatment option for these pathologies.

V316

Robotic Left Hepatectomy for Metastatic Colon Cancer to the Liver

Iswanto Sucandy, MD, Sharona B Ross, MD, FACS, Janelle D Spence, BA, Sydni Schlosser, Alexander S Rosemurgy; Florida Hospital Tampa

Introduction: Metastatic colorectal cancer to liver is the most common non-primary liver malignancy. Robotic liver resection has been considered as a unique opportunity to overcome the limitations of conventional laparoscopy, therefore, it can potentially extend the indications of minimally invasive liver surgery. Robotic liver resection is still considered in developmental phase within the discipline of liver surgery. Technical details of this operation have not been widely available in the literature. Herein, we report are technique of robotic formal left hepatic lobectomy.

Methods: Techniques of robotic left hepatectomy for metastatic colon cancer to liver is described. A video is attached to this report.

Results: A 49 year old man with history of sigmoid colectomy followed by adjuvant FOLFOX and Avastin presented to the office with single 4 cm PET avid segment 4 lesion. Past medical history was unremarkable. Robotic formal left hepatic lobectomy was undertaken using a surgical system. The left hepatic lobe was mobilized by taking down the left coronary and triangular ligaments. Inflow vascular structures were anatomically dissected using extrahepatic Glissonian approach. The left hepatic artery and portal vein were ligated prior to starting parenchymal transection. Left hepatic bile duct and left hepatic vein were transected intrahepatically using linear staplers. The left hepatic lobe containing tumor was removed using a laparoscopic extraction bag. Operative time was 180 min with < 75 cc blood loss. Postoperative hospital recovery was uneventful and the patient was discharged home on postop day 3.

Conclusion: Robotic formal left hepatic lobectomy is a safe and feasible minimally invasive option for metastatic colorectal cancer to the liver with excellent outcomes. This approach should be included in the armamentarium of modern liver surgeon.

V317

Jejunal Perforation by a Wire Grill-Cleaning Brush Bristle

Erin M Thompson, MD, John Romanelli, MD; Baystate Medical Center

Injuries from unintentional ingestion of wire grill-cleaning brush bristles have been increasingly reported in the literature over the past decade. Although a special report was published by the CDC in 2012 warning of this pattern of injury, case reports continue to appear in both the medical literature and the mainstream media. Widespread awareness of this grilling hazard is needed for both prevention and prompt diagnosis of these injuries. Here, we present a case of jejunal perforation from a wire grill-cleaning brush bristle repaired laparoscopically, as well as a review of the diagnosis and management of these injuries.

V318

Mirizzi Sindrome type III-IV, Non anastomosis laparoscopic resolution

Rene M Gordillo, MD, FACS, Amber R Andrade, MD, Wilson H Vasquez, MD; Ecuadorean Institute of Social Security

Objective: To report a case of Mirizzi syndrome type III, which was resolved laparoscopically.

Materials and Methods: Mirizzi Syndrome, a benign extrinsic compression of the common hepatic duct by a stone impacted in the cystic duct or the neck of the gallbladder, is a rare pathology. The surgical management of Mirizzi Syndrome type III and IV has been based on a bilioenteric derivation. In recent years most of the surgical procedures have been replicated laparoscopically and although in this syndrome its use is still considered controversial, we propose its treatment by laparoscopy without performing a biliodigestive bypass.

Results: The patient object of this report evolved favorably, without complications and the tasks of the surgery were fulfilled.

Discussion: The laparoscopic resolution of SM type III to date has only been reported sporadically, however in the cases performed it has been shown to be effective.

Conclusion: An analysis carried out by a committee of experts is important in order to establish current treatment guidelines for this pathology.

V320

Video Presentation: Laparoscopic Central Pancreatectomy with Pancreaticogastrostomy

Chaya Shwaartz, MD 1, Mor Aharoni, MD1, Joe Kim, MD2, Motti Cordova, MS1, Yuri Goldes, MD1; 1Sheba Medical Center, 2Summit Medical Grouup

This is a case of a 45 years old female with no significant past medical history who was diagnosed with non functional PNET at the neck of the pancreas. On imaging the mass was the size of 2.5 cm, involving the main pancreatic duct. The pt was presented in a multidisciplinary meeting and the decision was made to continue to surgery.

After general inspection of the peritoneal cavity, the lesser sac was entered by dividing the gastrocolic omentum (from distal antrum up to the fundus of stomach including the short gastric vessels, so as to expose the tail of pancreas). Adhesions between the posterior wall of stomach and pancreas are released completely. Dissection of the inferior border of the pancreas and mobilisation of its posterior surface are performed by retracting the transverse colon downwards and dividing the anterior layer of the transverse mesocolon.

Dissection is continued until the splenic vein is identified. The junction of the splenic vein and the superior mesenteric vein is identified. The pancreas along with the tumour-containing segment is dissected from the splenic vein, so as to have a 1 cm margin distally and proximally. Mobilisation of the body of the pancreas is done beyond the portal vein. Batressed Endo GIA stapler is used to divide the pancreas proximal to the tumour.

Distal pancreatic stump is anastomosed to the stomach intracorporeally. Postoperatively the patient was doing well. Pathology report showed 2.5 cm PNET well differentiated G1 tumor with Ki67 2% with no lymphovascular invasion or perineural invasion. Clean margins and no lymph node metastasis.

To conclude laparoscopic central pancreatectomy is a feasible and safe procedure. This surgery saves pancreatic tissue and preserving the spleen. However, pt selection and disease selection are crucial.

V321

Laparoscopic Enterolithotomy for Gallstone Ileus Seven Months after Laparoscopic Sleeve Gastrectomy

Aaron L Sabbota, MD, PhD 1, Huy Hoang, MD2, Amy Yetasook, MD1, Keith Boone, MD1, Pearl Ma1, Kelvin Higa, MD1; 1ALSA Medical Group, Fresno Heart and Surgical Hospital, 2UCSF Fresno Department of Surgery

Gallstone ileus is a rare cause of small bowel obstruction. This pathology is more common in elderly patients and is associated with considerable morbidity and mortality. We present a case of a 62 year-old morbidly obese female with a body mass index (BMI) of 45 presenting with abdominal pain, distension and bilious emesis seven months status post laparoscopic sleeve gastrectomy (LSG). BMI prior to LSG was 56. Patient was successfully treated with laparoscopic enterolithotomy and discharged on post-operative day 2. This video reviews the preoperative EGD prior to consideration for LSG. A small duodenal nodule was noted and biopsies showed normal duodenal mucosa. In retrospect, the intraoperative EGD performed at the time of laparoscopic sleeve gastrectomy showed signs of impending cholecystoduodenal fistula as there was significant omental adhesions to the right lobe of the liver obscuring visualization of the pylorus and a large mass noted in the proximal duodenum. CT scan obtained upon presentation of obstructive symptoms revealed a high-grade bowel obstruction with impacted stone in the mid-jejunum with concurrent pneumobilia. Lastly, the laparoscopic technique utilized for gallstone extraction and small bowel enterorrhaphy is displayed.

V322

Fluorescent Cholangiography as a Tool to identify a Hypoplastic Gallbladder and Critical Structures

Joel S Frieder, MD, Abraham Betancourt, MD, Fernando Dip, MD, Maria Fonseca Mora, MD, Cristian Milla Matute, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Indocyanine Green (ICG) has proven to aid in the intraoperative identification of biliary structures. The main advantages of this fluorescent technique are avoidance of bile duct incision, avoidance of bile duct injuries and its low costs. This is the case of an 18-year-old female with a BMI of 42, who was scheduled for a Laparoscopic Sleeve Gastrectomy with concomitant Laparoscopic Cholecystectomy. Preoperative abdominal ultrasound reported a contracted gallbladder with multiple calculi and sludge obscuring the lumen, no suggestive signs of cholecystitis. After a successful gastrectomy, we proceeded to perform the cholecystectomy. With the aid of ICG cholangiography the gallbladder was identified, and noted to be of small diameter. The cystic duct, common hepatic duct, and common bile duct were all clearly identified with this technology. The procedure was successfully concluded. Pathologic analysis revealed a gallbladder of 1.8 × 0.7 × 0.7 cm, chronic cholecystitis and no calculi.

V323

Watch and Wait Approach in Rectal Cancer - Endoscopic Response

Shruti Sevak, MD, Arman Erkan, MD, Alvaro Mendez, MD, Justin Kelly, MD, FRCS, George Nassif, DO, FACS, Teresa Debeche-Adams, MD, FACS, FASCRS, Matthew R Albert, MD, FACS, FASCRS, John Rt Monson, MD, FRCS, FACS, FACRS; AdventHealth

Pioneering studies from Brazil have suggested that surgery can be safely omitted in carefully selected patients with a clinical complete response after chemoradiation. Today, this is known as the "watch and wait" approach. As a novel approach to rectal cancer treatment the watch and wait algorithm offers us the opportunity to pursue organ preservation. Ultimately, these decisions should be made in a multidisciplinary setting. In this video we present two patients who have undergone neoadjuvant chemoradiation with endoscopic evidence of complete and partial response. We also discuss the approach to follow-up treatment for these patients.

V325

Laparoscopic Duodenojejunostomy for SMA Syndrome

Andrew M Brown, MD, Courtney L Devin, MD, Lauren Rosenblum, BS, Francesco Palazzo, MD, Michael J Pucci, MD, Ernest L Rosato, MD; Thomas Jefferson University

The video shows the steps undertaken for a laparoscopic duodenojejunostomy for the treatment of SMA syndrome. Laparoscopic duodenojejunostomy appears to be a safe and effective treatment for SMA syndrome.

V326

Laparoscopic Morgagni Hernia Repair: a case report

Marco Di Corpo, MD, Ann Chung, MD, Carlos Fajardo, MD, Timothy Farrell, MD; University of North Carolina

This is a case report of a 53-year-old female who presented to our clinic with a many year history of shortness of breath. Over the past 3 months, the shortness of breath had progressed to the point where she required supplemental oxygen at night. Her only other symptoms are occasional heartburn and regurgitation; she denies all other symptoms.

CT scan: Demonstrate a large midline anterior diaphragm hernia, presumably a Morgagni hernia, with the majority of her intraabdominal viscera herniated into her thoracic cavity and compressing her left lung.

Surgery: Laparoscopic Morgagni Hernia Repair

Trocars were placed in a similar position to that of a 5-port technique for antireflux procedures. A large midline anterior defect in the diaphragm was immediately identified. Due to the hernia, the contents of the intraabdominal cavity were displaced, finding the appendix lying in the left upper quadrant close to the spleen.

We began by reducing the contents of the hernia back into the abdominal cavity (small bowel, colon and greater omentum). Adhesions were divided to complete reduction. The left lung was clearly visible and we ensured that there would be no issues with lung entrapment from the chronic hernia by having anesthesia fully inflate the lung. The defect measured 6 cm wide and 7 cm in height. We performed a two layer primary repair of the hernia. First, we closed the defect in an interrupted fashion with nonabsorbable suture with pledgets using a combination of intracorporeal suturing and a suture needle passer. We then performed a second layer with a running no absorbable barbed suture. This left a 6 cm suture line.

We then inserted a 6 × 15 cm composite mesh to cover the suture line. The mesh was secured using a combination of nonabsorbable suture and absorbable. Finally, we administered fibrin-glue over the mesh to help boster the mesh in place. The mesh was well-fixated and centered over the primary defect.

The patient tolerated the procedure well. She was started on a diet immediately postoperatively. By the time of discharge on post operative day 2, she was completely on room air and not requiring any supplemental oxygen and noting an improvement in her pulmonary symptoms.

She was seen in follow-up at 1 month and was not having any symptoms. She was continuing to do well at 3 month follow up.

V327

Laparoscopic Management of SBO Secondary to Fitz-Hugh-Curtis

Jarvis Walters, DO 1, James Randall1, Fred Brody, MD, FACS2; 1George Washington University Medical Center, 2Veterans Affairs Medical Center

Some patients with pelvic inflammatory disease develop "violin string" adhesions between the anterior border of the liver and the abdominal wall. This syndrome is known as Fitz-Hugh-Curtis. This video depicts a case of laparoscopic lysis of adhesions due to small bowel obstruction secondary to Fitz-Hugh-Curtis Syndrome.

V328

Near-Bloodless Laparoscopic Liver Resection Using Microwave Pre-plane Ablation in Cirrhotic Patients

Morgan M Bonds, MD, Janelle Rekman, MD, George Baison, MD, Adnan Alseidi, MD; Virginia Mason Medical Center

Resection of hepatic malignancies in cirrhotic patients present a unique challenge to surgeons. Due to the need to preserve liver parenchyma in these cases, non-anatomic resection with close surgical margins is the procedure of choice. This technique can lead to increased blood loss which is exacerbated in cirrhotic patients with portal hypertension. These challenges are more arduous when attempting laparoscopic resection. In this video, we present microwave pre-plane ablation as a technique to achieve hemostasis prior to liver parenchymal transection. Microwave pre-plane ablation is demonstrated in two cases. In both instances, the tumors were successfully resected with less than 50 cc of estimated blood loss and the patients were discharged within 36 hours. The video is a cognitive task analysis modular video that includes tips for success and pitfalls when performing microwave pre-plane ablation and parenchymal transection during laparoscopic liver resection in patients with cirrhosis.

V329

Total gastrectomy with Roux-en-Y reconstruction for neuroendocrine gastric neoplasm.

Rene Aleman, MD, Joel S Frieder, MD, Carlos Rivera, MD, Federico Serrot, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Neuroendocrine tumors of the stomach are a less common type of gastric neoplasms reported in 8.7% of gastric. We present the case of a 69-year-old male with a 5-month history of a high-grade neuroendocrine tumor of the gastric body. Initially, the patient complained of chronic bloating and anemia-associated symptoms which led to an initial endoscopy. The patient received 4 rounds of neo-adjuvant chemotherapy, but the chemotherapy was suspended due to thrombocytopenia. The patient was scheduled for total laparoscopic gastrectomy (TLG). The patient made an uneventful recovery and the final pathology was consistent with a gastric neuroendocrine tumor (GNT) type 1.

V330

Gastric Sleeve Following Dor Fundoplication

Kais A Rona, MD, Hector M Morales, Christopher Ducoin, MD; Tulane University School of Medicine

Sleeve gastrectomy is the most common bariatric procedure performed in the United States. Recent literature has demonstrated a non-negligible rate of worsened gastroesophageal reflux symptoms and even de-novo reflux following sleeve gastrectomy. There are technical aspects of a sleeve gastrectomy that may help preserve the body’s natural anti-reflux mechanisms. Less is known about the approach for sleeve gastrectomy in a patient who has undergone a previous fundoplication for reflux. We believe that preservation of the wrap would be important in this patient population given the theoretically higher risk of reflux following sleeve gastrectomy. In this video we demonstrate a sleeve gastrectomy technique in which the wrap is preserved in a patient with a previous history of Heller myotomy with Dor fundoplication.

V331

Stent Migration in Gastroesophageal Junction Gastric Adenocarcinoma with Management of Perforation

Linda I Yala, MD 1, Rami Lutfi, MD, FACS, FASMBS2; 1UIC-MGH General Surgery Residency, 2Mercy Hospital, Chicago, IL

Introduction: In obstructing gastroesophageal junction tumors, self-expanding metal stents are often a means of palliation. Several studies have demonstrated that most common indication is for severe dysphagia and placement results in significant improvement therefore acting as a sufficient treatment option to restore swallowing function. However, complication rates associated with stenting ranges from 22 to 45% on various studies. A known complication of stent utilization is its migration for which an independent risk factor is adjuvant chemotherapy or radiation therapy. Much rarer but still prevalent are the cases of perforation.

Methods: We presented a 58-year-old male with a past medical history of alcohol and tobacco abuse and gastric adenocarcinoma who presented with substernal chest pain after eating. His CT scan at diagnosis demonstrated unresectable disease. At another facility, he underwent GEJ stenting to palliate, chemotherapy was initiated, and, one week prior to admission, he was noted to have stent migration due to his complete response to chemotherapy. An unsuccessful attempt to remove the stent at the facility prompted him to later present with findings of free air necessitating urgent operative intervention.

Surgery was performed by a trained laparoscopic surgeon with intent to convert to open if patient did not tolerate or needed more urgent damage control. He had purulent peritonitis and the greater curvature of the stomach had erosion of the stent with a large perforation below the hiatus. The decision was made to remove the stent as it was unlikely that the perforation would heal and the gastric erosion would progress.

Greater curvature was mobilized, lesser sac was entered, and a gastrotomy was created. With difficulty, the stent was freed. We then created a vascularized omental pedicle. The gastrotomy was closed and the pedicle was mobilized and loosely sutured into place. After drain placement and stent retrieval, the case concluded remaining entirely laparoscopic.

Conclusion: Self-expanding stents are increasingly being utilized in gastroesophageal junction tumors as palliation most often for severe dysphagia. All patients experience improvement in dysphagia after stenting however there are known risks associated including migration, perforation, fistulae, and bleeding. Stent migration is known to occur after chemotherapy and typically perforation is common immediately after placement, however, late complication of perforation is rare. We report a unique case where a patient had palliative stenting that was complicated by migration and the attempted retrieval of the stent in setting of friable tissue likely induced perforation and repair was completed laparoscopically.

V332

Hiatal Hernia Repair with Mesh and Toupet Fundoplication

Matthew E Sharbaugh, DO 1, Kristin Mccoy, MD2, Tejinder P Singh, MD1; 1Albany Medical Center, 2Stamford Health

Optimal hiatal hernia repair technique has yet to be standardized. There is still no consensus on the multiple technical aspects of the procedure including: mesh fixation, division of short gastric vessels, size of wrap, use of gastropexy and many more. The aim of our study was to evaluate the use of the robotic platform for hiatal hernia repair and demonstrate our standardized repair.

Our patient was a 75-year-old female who was suffering from dysphagia and gastroesophageal reflux which had caused her to undergo a significant weight loss. Her workup included a manometry study which showed normal contractility in the esophagus, an EGD which showed a large hiatal hernia with the GE junction located above the hiatus, and a upper GI series which demonstrated a 15 cm by 8 cm type 4 hiatal hernia.

The patient is positioned in reverse trendelenburg. The first step consists of the dissection of the greater curvature of the stomach using ultrasonic shears to transect the short gastric vessels. Next the gastric fundus is fully mobilized. We continue this dissection until the left crus of the diaphragm is visualized. The dissection is then carried across the anterior hiatus from left to right where we then enter the pars flaccida and identify the right crus. The dissection continues until the two planes are joined. Next the esophagus is mobilized from the posterior mediastinum to ensure adequate length in the abdomen and then encircled with an umbilical tape.

The hiatus is closed with figure of eight sutures. It is important to reapproximate the crura by lifting the esophagus and including the superior portion of the left crura as this is the most common site of recurrence. Next a mesh is anchored to the left and right crus of the diaphragm. The previously mobilized fundus is brought posterior to the esophagus and a 300 degree toupet fundoplication is created. The fundus is anchored to both crura and to the mesh which we believe is an important step in reducing recurrences. The fundoplication is created in a “V” like fashion to recreate the valve mechanism of the GE junction. The final product is a 300 degree wrap with 3 cm length of the fundoplication anchored in the abdomen. As the final step an endoscopy is performed to ensure proper passage through the gastroesophageal junction. The endoscope is retroflexed to evaluate for proper fundoplication effect.

V333

Single-port distal gastrectomy with D2 lymphadenectomy using a novel articulating grasper

So Hyun Kang, Yo-Seok Cho, Sa-Hong Min, Young Suk Park, Sang-Hoon Ahn, Do Joong Park, Hyung-Ho Kim; Seoul National University Bundang Hospital

Purpose: This report describes the benefits and drawbacks in the use of a novel articulating device (Artisential), which has a multi-degree wrist freedom like the Davinci endowrist, in performing complete single-port D2 lymph node dissection (LND) in single-incision distal gastrectomy (SIDG).

Methods: The Artisential was used in performing SIDG with D2 LND for patients with advanced gastric cancer. All operations were performed by a single surgeon using a three-dimensional camera and a passive scope holder in place of a scopist. The Artisential was used mainly in the 4sb and suprapancreatic LND, an area that is relatively far from the single port. In certain cases when the pancreas needed to be pushed down, such as obese male patients, the intraabdominal organ retractor was used to lift the tissue and the Artisential to push the pancreas. Operative results and short-term outcome were analyzed.

Results: Twelve patients underwent the procedure without any intraoperative events, conversion to conventional laparoscopy, or surgery-related complications including postoperative pancreatic fistula. All patients underwent single port D2 LND by complete exposure of the portal and splenic vein. Mean operation time was 181.9 ± 42.5 min. and mean number of retrieved lymph nodes was 61.8 ± 11.4. The Artisential was found to be useful in grasping the tissues behind the pancreas and the major arteries throughout most of the LND. The articulating motion also allowed the narrow single-port field of view to be clearly seen without the instrument body obstructing the camera.

Conclusion: The use of Artisential in SIDG appears feasible and reproducible, and is mandatory in performing a complete D2 LND in SIDG.

V334

Laparoscopic partial splenectomy with evisceration resection strategy

Mark L Kovler, MD 1, Seth D Goldstein, MD, MPhil2, Daniel S Rhee, MD, MPH3; 1Johns Hopkins Hospital, 2Lurie Children’s Hospital, 3Johns Hopkins Children’s Center

Introduction: Partial splenectomy has emerged as a surgical option for children with benign splenic tumors. The goal of complete resection while preserving splenic function is logical. However, laparoscopic partial splenectomy remains technically challenging. We present a novel technique for laparoscopic partial splenectomy with evisceration resection strategy.

Presentation of case: A 5 year-old female presented to our surgical clinic for evaluation of an upper pole splenic mass discovered during a work up for abdominal pain. Imaging suggested the mass was a benign tumor. Given her persistent abdominal pain and the benign features, we performed a laparoscopic partial splenectomy with evisceration resection strategy.

Video Content: The patient was positioned supine with a bump placed under the left side. An umbilical port was placed and inspection of the abdomen revealed splenomegaly. Left upper quadrant and epigastric ports were placed. The short gastric vessels were divided. Hilar inspection identified a superior branch of the splenic vasculature, which was divided using an endoscopic stapler. The remaining attachments were divided and complete splenic mobilization was accomplished. The spleen was eviscerated through a transverse mini-laparotomy in the left upper quadrant. Extracorporeal resection of the tumor was performed. After fascial closure, the remnant was inspected laparoscopically for proper anatomic position and hemostasis.

Outcome: Length of stay was two days. The patient has had sustained resolution of preoperative abdominal pain. Pathology demonstrated a benign hamartoma.

Conclusion: Evisceration resection strategy is a safe and feasible technique for performing laparoscopic partial splenectomy in children.

V335

Complex Cases of Choledochlithiasis: Robotic CBD Exploration

Adel Alhaj Saleh, MD, MRCS, Edwin O Onkendi, MBChB; Texas Tech University, Health Sciences Center

Post-operative Course:
  • The patient recovered smoothly and was gradually advanced to full diet and was discharged on POD#1

  • He was seen in the clinic 2 weeks after the procedure had no issues.

  • Pathology was benign

  • The CBD stent was removed 4 weeks postoperatively by ERCP

Patient # 1:
  • A 52 year-old female with h/o Roux-en-ygastric bypass

  • Presented with right upper quadrant abdominal pain x3 days associated with vomiting

  • She was found to have acute cholecystitis with high wbc count.

  • PMH: breast cancer, DM, MDD, HTN, Dysilpidimia

  • PSH: Mastectomy, Roux-en-ygastric bypass

  • She also has increased bilirubin

  • Abdominal USS showed bile duct stones and dilated common bile duct.

  • A previous attempt at ERCP had failed due to prior gastric bypass.

  • The patient was planned for robot-assisted cholecystectomy and common bile duct exploration

Conclusion:
  • Robotic CBD exploration after Roux-en-Y gastric bypass is a great alternative to laparoscopic assisted intraoperative ERCP for clearance of bile duct stones.

  • In morbidly obese patients robotic CBD exploration, is much less challenging than laparoscopic approach and provides the patient a minimally invasive clearance of CBD stones that would otherwise require open CBD exploration

Postoperative Course:
  • The Patient had an uneventful postoperative course

  • Gradually advanced to full diet and was discharged on POD #2

  • Scheduled to be seen in the clinic in 1 month.

Patient # 2:
  • A 53-year-old morbidly obese male presented with obstructive jaundice

  • CT scan of the abdomen showed multiple common bile duct stones and cholelithiasis.

  • Bilirubin was 14.

  • Attempt at ERCP wasn’t successful because he had large stones, with one mid bile duct stone causing obstruction and bile duct dilatation and multiple other large stones.

Operation:
  • Robotic common bile duct exploration, choledechotomy, removal of 7 large stones

  • Robotic Cholecystectomy.

V336

Lymphoproliferative Disorder T Associated with EBV Causing Massive Splenomegaly

Jara Hernandez Gutierrez, Aurelio Francisco Aranzana Gomez, Juan S Malo Corral, Beatriz Muñoz Jimenez; CH Toledo

Introduction: The aim of this video is to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. Currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the case of a massive splenomegaly or neoplastic pathology.

Methods and Procedures: Clinical case: A 38-year-old man studied by Internal Medicine for a hepatosplenomegaly of probable lymphoproliferative origin. Additional explorations of interest are provided.

Results: Full laparoscopic surgical approach in right lateral partial decubitus position: massive splenomegaly (> 23 cm), splenuncle of 3–4 cm. 4 trocars - lateral transabdominal approach. Laparoscopic section of short vessels, dissection of the splenic hilum, vascular section with EndoGIA, splenectomy with full extraction in a bag through reduced laparotomy in the left flank for pathological study. Correct postoperative recovery, discharge on the 3rd day.

Conclusion(s): In experienced laparoscopic surgical teams and selected patients with massive splenomegaly, the laparoscopic approach is a valid and safe alternative.

V337

Robotic Right Colectomy with Complete Mesocolic Excision and Intracorporeal Anastomosis: Bottom-to-Up Suprapubic Approach

Paolo P Bianchi, MD, Sofia Esposito, MD, Giuseppe Giuliani, MD, Lucia Salvischiani, MD, Adelona Salaj, MD, Giampaolo Formisano, MD; Ospedale Misericordia Grosseto, Italy

Introduction: Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL) could improve oncologic results. However, it’s a technically challenging procedure due to the wide range of anatomical variability of the major vascular structures. We herein describe a bottom-to-up approach for robotic right colectomy with CME and intracorporeal anastomosis using the Da Vinci® Xi Surgical System (Intuitive surgical Inc., Sunnyvale, CA, USA).

Methods and Procedures: The patient is an 82 years old man (American Society of Anesthesiologists score 3, Body Mass Index 27) with histologically proven adenocarcinoma of distal ascending colon. The patient is supine with a slight Trendelemburg and left tilt (5–10°). Three 8-mm and one 12-mm (for stapler) robotic trocars are placed along a horizontal line, about 2–3 cm above the symphysis pubis. A 12-mm assistant port is inserted in the left flank.

The mesenteric root is detached with a bottom-to-up approach from the Gerota’s fascia till the duodenum is exposed, preserving the integrity of the posterior mesocolic layer. The last ileal loop is then displaced caudally and the visceral peritoneum is incised along the axis of superior mesenteric vessels. Ileocolic vessels are ligated together at their origin. Lymph node dissection is carried out in a caudal-to-cranial manner along the anterior aspect of the SMV. Careful dissection is continued until Henle’s trunk is exposed. Right colic artery, located posterior to the SMV as in 10% of cases, is dissected. Superior right colic vein and right branch of middle colic artery are divided at their roots. After assessment of bowel perfusion with indocyanine green-enhanced fluorescence, a robotic stapled side-to-side ileocolic anastomosis is performed and the remaining enterotomy is closed with a double-layer barbed running suture. A mini-suprapubic incision (resulting from the connection of the two paramedian suprapubic trocar sites) is used for specimen extraction.

Results: Operative time was 170 minutes. The patient was discharged on postoperative day 4 with no complications. Pathology reported adenocarcinoma G2 (TNM stage: pT2N0, 31 harvested nodes).

Conclusions: Bottom-to-up approach for right colectomy provides a good frontal visualization of the superior mesenteric axis and allows for a safe central vascular ligation and exposure around the Henle trunk. This approach is feasible and safe and facilitates a sharp dissection along embryological planes with preservation of the integrity of proper mesocolic fascia.

V338

The Use of Lighted Ureteral Stents in the Case of a Duplicated Ureter

Laura Bradney, MD, Riva Das, MD, Andrea Ferrara, MD; Colon and Rectal Clinic of Orlando

Iatrogenic injury to the ureter during minimally invasive colon and rectal surgery can be a detrimental complication. The advent of lighted ureteral stents (LUS) has aided in the identification and protection of the ureters in such cases. LUS help replace the tactile feedback that is possible in open abdominal surgeries.

This is a case of a 43-year-old male who underwent an elective prophylactic robotic total abdominal colectomy with ileorectal anastomosis for attenuated polyposis syndrome. A cystoscopy was performed by urology prior to the start of the procedure for elective placement of LUS. A right single ureteral orifice was identified, but on the left there were two ureteral orifices consistent with a duplicated urinary system. This is a congenital malformation in which the ureteric bud splits leading to two ureters draining a single kidney. It occurs in approximately 1% of the population. Two fiberoptic LUS were placed, one on the right and one on the left. The medial ureter on the left received a non-lighted stent. During the left-sided colonic dissection, both the non-lighted stent and the LUS were easily identified, and the ureters were protected throughout the procedure. The stents were removed at the end of the case. The patient progressed appropriately and was discharged from the hospital with no urologic complaints.

Although the recommendation for routine use of prophylactic ureteral stents is an area of debate in colon and rectal surgery, they have proven to be useful for timely identification of the ureter, immediate identification of an iatrogenic ureter injury, and identification of ureter pathology (duplication in this case) all of which can lead to cost effectiveness. In this particular case, the use of prophylactic LUS allowed for the identification of aberrant anatomy and subsequent protection of the ureters in a patient that would presumably be at higher risk for ureteral injury.

V339

Laparoscopic Robotic-Assisted Excision of Epiphrenic Diverticulum with Heller Myotomy and Dor Fundoplication

Enrique F Elli, MD, FACS, Tamara Diaz Vico, MD; Mayo Clinic Florida

We present the case of a 54-years-old female presenting with left upper quadrant and dysphagia for one year. Preoperative studies were performed. A CT scan and an upper GI showed an epiphrenic diverticulum; a manometry evidenced esophagogastric outflow obstruction with elevated lower esophageal sphincter pressure. The endoscopy confirmed the diagnosis.

Patient was selected to undergo a robotic excision of epiphrenic diverticulum and Heller myotomy with Dor fundoplication.

The procedure started by opening the gastrohepatic ligament and dissecting the hiatus. Short gastric vessels were divided and a retroesophageal tunnel was created to pass along a Penrose drain for retraction and exposure. Once the pillars of the hiatus were clearly identified, the esophagus was then circumferentially dissected into the mediastinum in order to find and isolate the epiphrenic diverticulum. An intraoperative endoscopy was performed to confirm the location of the diverticulum. Using monopolar hook and scissors, the vague nerve was identified and preserved. The diverticulum was completely isolated and dissected off from the mediastinum. It was a wide mouth diverticulum about 3 cm from the gastroesophageal junction. A 54 Taper bougie was introduced to guide the resection without strangling the esophagus. An endoGIA white load was fired across and the staple line was reinforced with 3-0 PDS suture in an interrupted fashion. Then, a myotomy was performed, extending it 5 cm up into the esophagus and 3 cm down into the stomach. Longitudinal fibers were carefully dissected, and the mucosa was identified. An intraoperative endoscopy was performed, without any evidence of leaks, and a wide open gastroesophageal junction. In order to keep the myotomy opened, several stitches were placed in between both the left and right crus and the same side of the myotomy. Lastly, A Dor fundoplication was performed.

The postoperative upper GI showed good passage through the esophagogastric junction and no evidence of leaks. The patient was asymptomatic and she was discharged on postoperative day 2.

V340

Laparoscopic Median Arcuate Ligament Release

Ajay Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS, FLCS, Dattaguru R Kulkarni, MS, Mch, Amol N Wagh, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Shekhar Jadhav, MS, FMAS, Soumya Chatnalkar, MBBS, Priyanka Saha, MBBS, Kushboo Kadakia, MBBS, Shivang Shukla, MBBS; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Median arcuate ligament syndrome (MALS) is extrinsic compression of coeliac axis by lower than normal median arcuate ligament commonly seen in young women with relative hypoperfusion downstream. Requires diagnosis by exclusion. Commonly used investigations include transabdominal doppler and CT angiography. Treatment options include percutaneous coeliac ganglion block and open reconstruction of the vessel. Minimally invasive options include percutaneous angioplasty.

The present case highlights laparoscopic median arcuate ligament release technique with minimal dissection & perpetuation of diaphragmatic crura providing equivalent surgical outcomes.

Median arcuate ligament syndrome can be efficaciously managed laparoscopically, is a safe & feasible option.

V341

Laparoscopic suture ligation of left gastric artery bleeding secondary to an adjustable gastric band

Yuan Kong, Dr, Bo Chuan Tan, Dr, Deborah Ng, Dr, Anton Cheng, Dr, Chun Hai Tan, Dr; Khoo Teck Puat Hospital

Introduction: Gastric band erosion into the lumen of the stomach or esophagus is a common complication of laparoscopic gastric band. Left gastric artery erosion from gastric band is a rare and potentially lethal complication. There are only two case reports found in the literature, both patients presented with haematemesis, one managed with angioembolization with coils of bleeding pseudoaneurysm of left gastric artery, the other had laparotomy and suture ligation of left gastric artery.

Method and result: We present a case of 33yo gentleman who previously had laparoscopic adjustable gastric bad done in 2006, presented in May 2018 for haematemesis secondary to gastric band erosion into left gastric artery. This case was managed with laparoscopic suture ligation of left gastric artery, removal of gastric band and closure of gastrostomy (details see in video presentation).

Conclusion: Bleeding from left gastric artery secondary to gastric band erosion is rare and a lethal complication. From the limited available literature, this can be managed surgically or via angioembolization. Choice of treatment will depend on the patient’s haemodynamic status and hospital facilities. The case highlights that laparoscopic surgery can be used to salvage this situation.

V342

Optiview “555 Manish Technique” for Tep Repair: An Innovative Technique

Manish Kumar Gupta, Associate Professor, Sarrah Idrees, Dr, Rathindra Sarangi, Dr; Sir Ganga Ram Hospital, New Delhi

Hasson trocar technique is the only technique known among laparoscopic surgeons to access the pre-peritoneal space (PPS) for TEP repair of inguinal hernia. The insertion of Hasson trocar in PPS is a relatively blind step and can accidently injure the peritoneum during insertion. This can result in difficult dissection and prolongation of operating time. The large cone of Hasson trocar needs to be fixed by anchoring sutures to the anterior rectus sheath (ARS). This fixation further tears the fibres of ARS & need repair at the end of surgery. Placement & fixation of Hasson trocar takes 7 to 10 minutes of operating time. Bigger wound causes more pain in comparison to 5 mm port wound. A 2.5-3 cm skin scar in the infra-umbilical region is also cosmetically less acceptable, especially to females.

We have innovated an optiview “555 Manish Technique” by which PPS is accessed by 5 mm visiport under complete vision without any dependence on Hasson trocar and anchoring sutures for Mini TEP repair.

An indigenous inexpensive second generation “Manish Retractor” (Patent filed) is made which plays a key role in inserting 5 mm visiport to access PPS under complete vision. We have also innovated a technique to introduce adequate size light weight polypropylene mesh through 5 mm port which facilitates in completion of surgery by all three 5 mm ports.

Results: We operated 160 male and 2 female patients. The average age of patients was 43.2 years. 160/162 cases were successfully completed by our technique. Two cases were converted to TAPP because of adhesions and difficult dissection. In 160 patients, 203 inguinal, 1 femoral & 1 obturator hernias were operated. The average duration of first 5 mm port placement to access PPS was 2.1 minutes which is far less than the Hasson trocar technique. Pain was less due to all 5 mm ports. Smaller 5 mm scars are cosmetically more acceptable to patients. We reported no recurrence or complications other than seroma on 6 months follow up.

Conclusion: “555 Manish Technique” is easy, less invasive, less morbid, time saving, cost effective & reproducible technique. There is no dependence on Hasson Trocar & it doesn’t compromise the principles of current surgical procedure.

V343

Laparoscopic Para-hiatal Hernia Repair

Benedict Hui, MD, Geoffrey Chow, MD; University of Oklahoma - Tulsa

This is a video submission showing laparoscopic repair of a parahiatal hernia. The patient is a 44 year old female who presented with heartburn, regurgitation and chest pain. EGD and CT showed a type 3 paraesophageal hernia. Intra-operatively, we discovered instead a diaphragmatic defect adjacent to the hiatus through which the stomach had herniated. Although this has been reported in some case reports it is uncommon. We approached the repair laparoscopically with dissection of the right and left crus followed by dissection of the parahiatal hernia and reduction of the stomach. We then repaired the hernia defect and reinforced the repair with mesh. We concluded with a Nissen fundoplication.

V344

A Case for the Robot: the Difficult Gallbladder

Priya Rajdev, MD, Ankit D Patel, MD, FACS; Emory University

Over the last several decades, laparoscopic cholecystectomy has become the standard approach to operative diseases of the gallbladder. Now, as more surgeons are training in and adopting robotics around the world, the robotic approach to cholecystectomy is gaining popularity due to ability to gain finer dissection and improved visualization. A counterargument that is often presented to advocates of robotic cholecystectomies focuses on the increased time and cost compared to the laparoscopic approach. While this is true for straightforward cases, the more complex cases have a higher rate of conversion to an open approach. The case shown in this video demonstrates how we can take advantage of fully-articulating instruments, multiple arms, and three-dimensional visualization of the robot to perform a cholecystectomy with abnormal anatomy in a reoperative field.

V345

Robotic Gastric Bypass Reversal with Sleeve Gastrectomy

Anna E Martin 1, Dimitrios Stefanidis, MD, PhD2; 1Indiana University-Purdue University Indianapolis, 2Indiana University School of Medicine

Gastric bypass reversal is an effective rescue procedure for reactive hypoglycemia after a gastric bypass operation.

In this video, we present a Robotic Gastric Bypass Reversal with Sleeve Gastrectomy on a 45-year-old female who had undergone a gastric bypass in 2003 for morbid obesity. Over the past 9 months before her reversal, she had been suffering from severe reactive hypoglycemia. Medical treatment by endocrinology did not address her symptoms despite different attempted strategies with several episodes of hypoglycemia and related falls during the day. She was offered bypass reversal with sleeve gastrectomy to help her symptoms and maintain weight loss benefits.

For her operation, 4 robotic arms and an additional 12 mm laparoscopic port were used. Lysis of adhesions was extensive and took greater than 50% of the duration of this procedure. The gastric pouch was divided proximal to the prior GJ while the Roux was divided proximal to the J-J as it was fairly short (appr 30 cm). The Roux was then removed. The divided pouch was anastomosed to the gastric remnant using a handsewn technique. The remnant fundus was resected, and the rest of the gastric remnant was sleeved using the endoscope as the bougie. A leak test using EGD was negative.

The procedure was very demanding technically and lasted 6.5 hours but was accomplished safely. There were no intraoperative complications, and the patient was discharged home on POD #2. On 3 months follow up, the hypoglycemic episodes had completely resolved, and the patient had not regained weight. Enhanced 3D visualization, platform stability, and improved precision make the use of robotic surgery for complex foregut procedures appealing.

V346

Laparoscopic resection of solid pelvic mass

Matthew Romine, MD, Gregory Kennedy, MDPhD; University of Alabama at Birmingham

A forty-seven year old male presented with left leg pain for 3 months duration described as shooting pain. He underwent extensive testing including a CT and MRI of his pelvis demonstrating a left pelvic sidewall mass abutting his iliac vessels and left ureter. Based on imaging, the mass was concerning for an enlarged lymph node versus a nerve sheath tumor. EMG testing demonstrated normal neurologic function. Given location of the mass, he elected to proceed with surgical resection of the left pelvic sidewall mass.

The accompanying video demonstrates the laparoscopic surgical technique used to resect the mass. The case was particularly challenging given the mass resided next to the left iliac artery and vein with the ureter coursing over the mass.

Postoperatively, the patient returned to clinic free of any further episodes of preoperative pain nor complications from his surgery. Final pathology of the mass was unifocal Castleman’s disease, a rare lymph node disease, which is cured with surgical resection.

V347

Laparoscopic Heller Myotomy for Recurrent Aspiration Pneumonia Following Gastric Bypass

Courtney L Devin, MD, Andrew M Brown, MD, Michael J Pucci, MD, Francesco Palazzo, MD; Thomas Jefferson University

The video shows the steps undertaken for a laparoscopic Heller myotomy for recurrent aspiration pneumonia following gastric bypass. While the incidence of achalasia and other esophageal motility disorders in the bariatric population are unknown, it should be treated when identified.

V348

Laparoscopic Incisional Hernia Repair with Simultaneous Gastric Bypass in a Morbid Obese Patient

Enrique Arias, MD 1, Angel Henriquez, MD1, Luis Martinez, MD1, Alexander Ramirez, MD, FACS2; 1INTERLAP, 2Tallahassee Memorial Hospital

41 years-old male with a long term history of morbid obesity, hypertension, hyperlipidemias and obstructive sleep apnea, he came for a bariatric procedure. He had an open appendectomy 25 years ago, and 15 years later he felt a growth in the incisional area. Physical examination at the time of surgery reported a weight of 317 lbs (144.1 kg), BMI of 45.4 kg/m2, an outward bulging of tissue was found at the right lower abdominal area which was impossible to reduce. The ultrasonography reported a 7 × 5 cms hernia sac and an hernia defect of approximately 3 cms of diameter. Laparoscopic gastric bypass was planned, it was necessary to reduce the contents of the hernia sac during the surgery, a standard Roux-en-Y gastric bypass was performed with a simultaneous ventral hernia repair using a coated polypropylene mesh. Hospital stay lasted 48 hours, and he had an uneventful recovery

V349

Roux-en-Y Gastric Bypass Surgery in Situs Inversus Patient

Caolan Walsh, MD, FRCSC, MBA, Amer R Jarrar, MD, Gabriel Roy, MD, FRCSC, Joseph Mamazza, MD, FRCSC; The Ottawa Hospital, University of Ottawa

61-Year-old Female presenting for Roux-en-Y Gastric Bypass Surgery, the patient has a complete mirror image of her intra-abdominal viscera; a case of Situs Inversus totalis

After undergoing pre-operative assessments the patient is brought into the operating room and the surgery is carried out, in this video, we showcase the important parts of the surgery highlighting the difficulties faced when operating on such a case.

Postoperatively the patient is recovering and has lost a total of 44 pounds after 8 weeks.

V350

Laparoscopic Repair of Incarcerated Recurrent Parastomal Hernia

Stephanie Novak, MS, Zachary Callahan, MD, Stephen Haggerty, MD, FACS; NorthShore University Health System

We present the case of a patient who underwent a laparoscopic modified Sugarbaker technique for an incarcerated recurrent parastomal hernia. The patient is a 76-year-old male with multiple medical problems. He had a prior laparoscopic parastomal hernia repair in 2011, which was done using the Sugarbaker technique. Lysis of adhesions was performed and the recurrent parastomal hernia with incarcerated small intestine was identified. We proceeded with another Sugarbaker repair of the recurrent hernia since this technique has been shown to have the lowest recurrence rate in several studies. Tacks and transfacial sutures were used to ensure excellent fixation of the mesh. Based on the literature and on our own clinical practice, we conclude repeat laparoscopic Surgarbaker mesh repair is feasible and effective for recurrent parastomal hernia.

V351

Laparoscopic Radical Cholecystectomy for Gallbladder Carcinoma

Shashikiran J Nanjakla, Hemanga Bhattacharjee, Praveen Kumar, Manjunath Bale, Ajit Oberoi, Suhani Suhani, Rajinder Parshad; All India Institute of Medical Sciences,New Delhi

Introduction: Gallbladder malignancy is the most prevalent biliary tract malignancy in India. Laparoscopy was restricted only for staging purposes initially in view of concerns regarding feasibility of achieving an adequate Liver margin, lymph node yield and the risk of intraoperative peritoneal dissemination.

Methods and procedures: Patient positioned in French position under general anesthesia. Pneumoperitoneum was created from supraumbilical incision. 12 mm camera port inserted and staging laparoscopy done which did not reveal any evidence of metastasis. Two more 5 mm ports inserted just above the level of umbilicus in right and left mid clavicular line. 12 mm port was placed just left of the midline in epigastric region. Duodenum was kocherized - Inferior Vena cava identified. Initial lymph node dissection started along the common hepatic artery and control was taken using the vascular sling, Dissection was continued up till the Hilum. CBD skeletonised and slinged away to harvest pericholedochal lymphnodes. Periportal lymph nodes harvested. Cystic duct and artery identified clipped and divided separately. Cystic duct margin was sent for frozen section analysis which came out to be negative for malignancy. Liver capsule scored with monopolar cautery with ~ 2.5-3 cm margin all around. Wedge resection done of segment 4b and part of segment 5 of liver using harmonic. Hemostasis achieved and no obvious bile leak noted. Drain placed and specimen removed in Endo bag from epigastric port site. Cut section revealed an ulcero-proliferative growth in the fundus limited to gallbladder wall without any stones. Postoperative course was uneventful, drain was removed on POD3 and patient was discharged on POD4. Total operative time was 240 minutes. Total blood loss was 200 ml.

Results: At our institute, we have been offering laparoscopic radical cholecystectomy to patients with suspected early-stage gallbladder cancer. Care is taken to avoid bile spillage and to achieve adequate lymph node harvest. The procedure was uneventful. Patient is doing well on follow up. Histopathology revealed a moderately differentiated adenocarcinoma pT2aN0M0 without any perineural or lymphovascular emboli. Liver wedge was free of tumor. None out of 12 lymphnodes were involved by the tumour.

Conclusion: Laparoscopic radical cholecystectomy is a feasible alternative to open radical cholecystectomy in selected cases.

V352

Laparoscopic transabdominal preperitoneal (TAPP) converted to totally extraperitoneal (TEP) right inguinal herniorrhaphy with mesh

Usah Khrucharoen, Yen-Yi Juo, Yijun Chen, Erik Dutson; UCLA

While surgeons occasionally convert from a totally extraperitoneal (TEP) approach to a transabdominal preperitoneal (TAPP) during laparoscopic inguinal hernia repair due to inadvertent peritoneum violation, it is infrequent for surgeons to convert from TAPP to TEP, due to the perceived difficulty in maintaining preperitoneal work space after the abdomen has been entered. We hereby present a patient with right inguinal hernia and a history of prior prostatectomy, leading to a decision to adopt a TAPP approach in order to avoid the previously entered preperitoneal space. However, significant intraabdominal adhesion was encountered upon entering the abdomen. In this video, we demonstrate our technique in converting from TAPP to TEP, whereby the umbilical port was reintroduced into the preperitoneal space. Pneumoperitoneum was reversed and adequate preperitoneal work space could be maintained. Postoperative course was uneventful, and patient was discharged on the following day.

V353

Laparoscopic Resection of Gastric Duplication Cyst

Richard Thompson, MD, Meredith Duke, MD, MBA; UNC

A 26 year-old female presented with months of right upper quadrant pain. Diagnostic imaging showed a small fluid collection adjacent to the gastric antrum, initially suspected to be an abscess. A percutaneous drain was placed with what was described as bilious aspirate. Endoscopic ultrasound with fine needle aspiration was performed, with cytology consistent with benign gastric mucosa. Her pain improved until the drain was removed; her symptoms then recurred. She was taken to the operating room for laparoscopic excision of the lesion, which proved to be a gastric duplication cyst.

V354

Robotic Assisted Distal Spleno-Pancreatectomy for Mucinous Cystic Tumor of Body of the Pancreas

LF Gonzalez Ciccarelli, MD, R Bustos, MD, M Masrur, S Gruessner, V Valle, F Bianco, P Giulianotti; University of Illinois at Chicago

Introduction: Whipple procedures are one the most challenging surgeries due to the pancreas location and vascular relations. Bleeding control can be a difficult task to overcome leading to increased blood losses and conversion.

Methods Procedures and Result: Patient is a 43 year old female with a PMH of DM and heroin abuse. Patient presented to OSH ER with withdrawal symptoms. CT scan was performed at OSH showed pancreatic cyst, the patient was referred to this institution for higher hospital care. EUS + FNA showed 6.1 × 4.7 cm mass, septate cystic lesion in the pancreatic body. Pathology showed a + ve mucin with BF CEA 4,039 and amylase of 262. CT scan showed a 6,8 × 4,9 × 4,8 cm transverse hypo attenuating lesion arising from pancreatic body with a thick circumferential wall. Inferior aspect of the mass abuts the splenic artery without narrowing. Medial portion involves the portal vein confluence with less than 90 degrees involvement with multiple splenic varices in the LUQ, suggest compression of the splenic vein by pancreatic mass. The patient was elected to undergo a robot-assisted distal spleno-pancreatectomy. Operative time was 282 minutes, overall estimated blood loss was 150 ml. No blood transfusions were necessary. The pathology report was consistent with mucinous cystic tumor 9.1 × 8.9 × 4.5 cm. The resection margins were negative with 11/11 negative lymph nodes. There were no intra or postoperative complications. On POD1 amylase 1435 with sudden drop to 46 at POD2 and 15 at discharge. The patient was discharged from the hospital on postoperative day 7. Four month follow-up patient is asymptomatic with no complains.

Conclusion: The robotic system has the potential to increase the safety of the procedure, facilitating the management of intraoperative bleedings with endowristed instruments and selective sutures, reducing overall blood loss and risk of conversion when compared to standard laparoscopy.

V355

Laparoscopic Esophageal Diverticulectomy with Heller Myotomy and Toupet Fundoplication

Benedict Hui, MD, Geoffrey Chow, MD; University of Oklahoma - Tulsa

We are presenting a laparoscopic esophageal diverticulectomy with Heller myotomy and Toupet fundoplication. The patient is a 51 year old male with 10 year history of achalasia previously treated with endoscopic dilation. He presented with worsening dysphagia, chest pain, and regurgitation of undigested food. We started by dissecting out the hiatus, followed by taking down the short gastrics and dissecting out the hiatal hernia sac and esophageal diverticulum. We then proceeded with the Heller myotomy. The diverticulum was then taken with the laparoscopic stapler and perfusion was examined with the laparoscopic near infrared camera using indocyanine green. The crura was then closed and we concluded with a Toupet fundoplication. The patient did well and had relief of his symptoms and an Eckhardt score of 0 on follow up.

V356

Omental Patch Repair For Perforated Duodenal Ulcer:Robotic Approach In A Patient With Delayed Presentation

Osvaldo Zumba, MD 1, Joanne E Glanville, MD2, George Mazpule, MD1, Stephen G Pereira, MD, FACS1, Adam Rosenstock, MD, FACS1; 1Hackensack University Medical Center, 2Surgical Associates of Richmond

The use of robotics to perform minimally invasive surgery has emerged as a viable option for most general surgery procedures. The robotic platform offers better visualization and allows for a minimally invasive approach for more complex procedures that require advanced surgical skills. Though the robot platform offers such a great advantage compared to laparoscopy, its use for emergent procedures has been limited. Specifically in patients with perforations of the GI tract, a laparoscopic or open approach is usually used for repair. Here we present the case of a 43-year-old male who, secondary to chronic NSAID use, had one week of epigastric abdominal pain. After workup, CT imaging of the abdomen reveal gross perforation of the proximal duodenum with extravasation of oral contrast. Though the patient likely had this perforation several days prior and appeared to be septic, we proceeded with a robotic approach for repair. This video shows our approach to the robotic omental/Graham patch in a patient with delayed presentation. Four days after his procedure, the patient’s upper GI imaging was negative for leak and he was able to tolerate a regular diet. Significantly, the patient’s abdominal pain resolved almost immediately after surgery and required minimal analgesics during his hospital stay. The robotic surgical approach offers the potential for expanded use in all general surgical procedures, including those that are traditionally managed open, such as a perforated duodenum in this case.

V357

Laparoscopic Repair of J-pouch Appendage Leak after Loop Ileostomy Reversal

Stewart Whitney, MD, Philip George, MD, Justin George; Icahn School of Medicine at Mount Sinai

Background: This is a 29 year old female with past medical history of severe Ulcerative Colitis, refractory to medical therapy, who in the past underwent a laparoscopic subtotal colectomy with end ileostomy, subsequently followed by restorative proctocolectomy with ileo-anal (“J-Pouch”) creation and diverting loop ileostomy, who presented for closure of the loop ileostomy.

She tolerated the procedure well, and had a routine post-operative course until POD3, when she began having increased pain, fevers, turbid fluid in the Jackson-Pratt drain, and a new leukocytosis. Because of these findings, she was taken to the operating room for re-exploration.

Video will be shown at this point. A leak from the tip of the J-pouch appendage is identified after air leak test, is dissected free, and a small bowel resection is performed to resect the portion that had been leaking. Following this, a repeat air leak test was performed, which was negative.

Conclusion: Suspicion for leak from pouch, even with negative imaging prior to diverting ileostomy closure, should be high in patients with sepsis in the early postoperative period after closure of loop ileostomy after IPAA. The“J-pouch”appendage is a frequent site of leak, and if surgical exploration is warranted, can be done laparoscopically

V358

Laparoscopic Median Arcuate Ligament Release

Marcoandrea Giorgi, MD, Todd Stafford, MD; Brown University - Rhode Island Hospita

Video illustration of laparoscopic median arcuate ligament release. The patient is a 27 years old female with acute on chronic epigastric abdominal pain associated to food intake associated with food fear, ultrasound Doppler and CT scan findings suggestive of median arcuate syndrome. She was taken to the operating room for laparoscopic ligament release.

V359

Laparoscopic Bilateral Inguinal Hernia Repair After Femoral-Femoral Bypass

Michael B Goldberg, MD1, Jessica Barton, DO 2; 1Crozer-Keystone Health System, 2Philadelphia College of Osteopathic Medicine

Inguinal hernia repair is one of the most commonly performed procedures in the United States. The totally extraperitoneal (TEP) approach is a widely accepted laparoscopic technique. We report the case of a laparoscopic bilateral inguinal hernia repair after femoral-femoral bypass. The patient is a 76-year-old man with history of a femoral-femoral bypass for claudication who presented with a symptomatic, enlarging left groin hernia in the region of his bypass. On exam, he had a reducible left inguinal hernia underneath a palpable vascular graft. Computed tomography scan revealed the graft above the rectus muscle with bilateral inguinal hernias in very close proximity. Totally extraperitoneal laparoscopic inguinal hernia repair was chosen as an open incision would directly interfere with the graft. The preperitoneal space was successfully dissected and additional ports were placed without disrupting the graft. Bilateral hernias were reduced and repaired with mesh using the TEP approach. The patient experienced no postoperative complications. In conclusion, laparoscopic totally extraperitoneal inguinal hernia repair is feasible for patients with extra-anatomic vascular bypass grafts in the inguinal region.

V360

A rare case of Castleman’s disease in the mesocolon and its successful laparoscopic management

Deepa Jahagirdar, Ashwinee Rahalkar, Raj Gajbhiye, Bhupesh Tirpude, Hemant Bhanarkar, Prasad Upganlawar; Government medical college, Nagpur, India

A 50 year/female patient admitted in our medicine department for fever, cough with expectoration and chest pain since 5 days. She was a known case of idiopathic thrombocytopenic purpura. She then developed pleural effusion of left side and later on developed empyema for which was treated. She was treated for all the above mentioned conditions in our hospital. She had undergone a series of investigations and was incidentally found to have a lumbar mass. On the basis of CT scan of abdomen and FNAC from the lumbar mass, the mass was thought to be a carcinoid tumour of the mesentery. The patient was then considered for surgical management after treating all other co-morbidities. The tumour was then removed laparoscopically. The tumour was situated in the mesentery of descending colon. The tumour was situated near the inferior mesenteric artery. During dissection of tumour the inferior mesenteric artery and its branches were safeguarded and tumour was dissected all around. The histopathological report of the excised specimen came out to be Castleman’s disease of solitary type. Castleman’s disease is an abnormal lymphoproliferative disorder first described by Dr Benjamin Castleman. There are very few documented cases of castleman’s disease in the mesentery and even fewer cases treated laparoscopically. No similar studies were seen with other co-morbidities as in our case. Also, in spite of all other co- morbidities, the patient was successfully treated for all those conditions and was discharged on post-operative day 12. Patient is found to be free of any symptoms during our regular follow up.

V361

Laparoscopic Completion Cholecystectomy

Ramesh M Punjani; Fortis Hospital, Mumbai

Laparoscopic Cholecystectomy (Lap Chole) for acute cholecystitis is a standard treatment. However, in some cases it is tricky. One has to be very close to gall bladder during dissection. We did lap chole in such setting. It appeared quite satisfactory, till 2 1/2 months when patient presented with pain & residual gall bladder with stones. We did laparoscopic completion cholecystectomy successfully.

V362

Management of Pericardic Gastric Diverticulum during Sleeve Gastrectomy

Anthony A Castelli, MD, Rami E Lutfi, MD, FACS, FASMBS; University of Illinois - Chicago Metropolitan Group Hospitals

We present two cases in which gastric diverticula were found in patients undergoing laparoscopic sleeve gastrectomy. In the first case, the gastric diverticulum was found incidentally during the procedure. Conversely, the diverticulum was found on preoperative transnasal esophagoscopy in the second case. In both cases, the diverticula were in the pericardic region of the stomach and were able to be incorporated in the gastrectomy specimen. There are currently no established guidelines regarding the management of incidental gastric diverticula during sleeve gastrectomy which is likely due to the rare prevalence of this abnormality. We recommend incorporating the gastric diverticulum within the gastrectomy specimen if possible. In addition, the operative plan would have differed if preoperative endoscopy demonstrated a diverticulum in the future stomach remnant. Though the use of preoperative endoscopy is controversial, it would have been beneficial to have had a preoperative esophagogastroduodenoscopy that demonstrated the diverticulum in order to anticipate it intraoperatively and make any changes to the operative plan as needed.

V363

Laparoscopic Ultra Low Anterior Resection

Phuong Vuong, MD; Oncology Hospital Of Ho Chi Minh City

Laparoscopic intersphinteric resection has been done at Oncology Hospital of HCM city since 2015.

Purpose: to evaluate the outcomes of this surgery.

Method: cases report study. There are 22 cases in this trial.

Results: males/females: 11/11; Average age: 54(32–70); rectal cancer 19 cases(stage 1: 2 cases, stage 2: 5 cases, Stage 3: 10 cases, stage 4: 2 cases); Rectal polypolypes: 3 cases; Preoperative chemoradiotherapy: 13/19 cases; Average distance from the lowest border of tumor to anus verge: 4.2 cm (3-7 cm); Adenocarcinoma grade 2: 18 cases, adenocarcinoma grade 1: 1 case; Average operation time 108.8 minutes (80–170 minutes); Average blood loss: 96,9 ml (10–200 ml); Ileostomy: 4 cases; Post operation discharge at day 7; Anus stenosis: 1 case (treated by anus dilation), Anastomosis recurrence: 1 case (APR was done); recto-vaginal fistule: 1 cases (redo the anastomosis).

Conclusion: Laparoscopic intersphinteric resection is safe and feasible.

V364

Laparoscopic D2 radical distal gastrectomy with complete mesogastrium excision for advanced gastric cancer

Wei Wang, Wenjun Xiong, Jin Wan, Xiaofeng Zhu; Guangdong Provincial Hospital of Chinese Medicine

Laparoscopic distal gastrectomy for advanced gastric cancer is widely perform in East Asia. Herein, we introduce the technique of laparoscopic D2 radical distal gastrectomy with complete mesogastrium excision.

First step was dissecting the gastrocolic omentum from left to right. The superior border of pancreas was exposed and the No.4sb and 4sa lymph nodes (LNs) dissection. Secondly, the right part of gastrocolic omentum was separate to expose the duodenum and pancreas head with No.6 LNs dissection. The Gerota fascia was dissected from pancreatic tail to pancreatic neck with the abdominal aorta, celiac trunk and its branches were exposed. The left gastric artery and vein were ligated and the No. 7, 8a, 9 and 11p lymph nodes were dissected. Exposing the right gastric artery and portal vein, the No.5 and 12a LNs were dissected. The lesser curvature of the stomach was separated and the No.3 lymph nodes were dissected. The third step was separating the lesser omentum to dissect No.1, 3 and 5 LNs. The mobilizing and dissecting procedure was finished.

LDG with D2 lymphadenectomy complete mesogastrium excision for advanced gastric cancer is technically feasible.

V365

Laparoscopic Repair of Giant Morgagni Hernia with mesh reinforcement

Indraneil Mukherjee, MD, Aleksandr Demin, DO, Andrey Mironenko, MD, Karen E Gibbs, MD, Aleksandra Ogrodnik, MD; Staten Island University Hospital

Introduction: Morgagni hernias are a rare congenital defect found in the anterior diaphragm between the costal margin and the sternum. The failure of fusion of the septum transverses during the 4th week of embryologic development produces the congenital tract just posterior to the sternum in the muscle free space of Larrey. Although rare these defects can be seen bilaterally. In the pediatric population the reported incidence is anywhere from 1 to 3%. Although most of these are asymptomatic, in this modern age they are more often diagnosed and repaired early making adult Morgagni hernias an uncommon entity. However, when symptomatic patients usually present with vague gastrointestinal and respiratory complaints. Progression of symptoms and complications include intestinal obstruction, perforation and ischemic bowel. Radiologic evaluation of these hernias is best performed with a Computerized tomographic scan to assess the size and content of hernia to plan for the surgical approach. Both Transthoracic and Transabdominal approaches have been used. Today Laparoscopic approach for the repair of the defect is more minimally invasive than Thoracoscopic approach.

Case Presentation: We present an 85 year old female with recurrent hospital admissions for gastric outlet obstruction treated with nasogastric tube decompressions. She was found to have a giant Morgagni hernia and was deemed too high risk for surgical repair. After we were consulted and having an informed consent she was taken to for a laparoscopic repair of the defect with mesh reinforcement. Intra-operatively the stomach and colon reduced spontaneously on insufflation. The small bowel and omentum was reduced. The adhesions between the omentum and hernia lip was lysed. The defect was found to be 10 cm in diameter. The hernia was repaired primarily by using trans fascial interrupted sutures to approximate the diaphragm to the anterior abdominal wall. This repair was reinforce with a coated light weight polypropylene. She was discharge next day. She has been asymptomatic since then.

Discussion: Morgagni’s hernia, a rare congenital anterior diaphragm defect is usually repaired early in life. In adults Morgagni’s hernias is an uncommon entity, usually detected radiologically when done for some other symptoms. Both Transthoracic and Transabdominal approaches have been used. Our video and review of literature does show Laparoscopic approach for the repair of such defect is feasible and even in extremely large hernias and safe in the geriatric population.

V366

Laparoscopic Conversion of Gastric Plication to Roux-en-Y Gastric Bypass

Agustin Duro, MD, Santiago Corradetti, MD, Patricia Saleg, MD, Fernando G Wright, MD, Axel F Beskow, MD; Hospital Italiano de Buenos Aires

Laparoscopic Gastric Plication (LGP) is a relatively simple, safe and low cost bariatric surgical technique, but with no consensus and unclear evidence about its efficacy and durability in terms of weight loss.

This video shows a 40-year-old woman without major comorbidities, who had undergone a LGP one year before consulting to our group. Despite an initial 19% excess weight loss in the first postoperative months, she then regained weight until reaching a BMI of 41 kg/m2 and started complaining of typical gastroesophageal reflux disease (GERD) symptoms. Barium swallow and endoscopy revealed a practically normal stomach anatomy in the fundus, with a progressive size decrease starting in the body. A conversion to Roux-en-Y gastric bypass (RYGB) was planned. Surgical technique included extensive lysis of adhesions between gastric fundus and greater omentum, partial gastrectomy of the fundus, with take down of the plication at that level and RYGB. The patient had no complications and was discharged on the second postoperative day. At 6 months, she has already achieved an excess weight loss of 61% with no GERD symptoms recurrence.

Although technically demanding, conversion to RYGB seems to be a safe, feasible and effective method to perform when LGP fails.

V368

Laparoscopic Total Gastrectomy with Roux-en-Y Esophagojujenostomy in a CDH1 Gene Mutation Patient with Morbid Obesity

Adel Alhaj Saleh, MD, MRCS, Amir H Aryaie, MD, FACS; Texas Tech University Health Sciences Center

A 27 year-old female (BMI of 51 kg/m2) came to us for prophylactic total gastrectomy after seeing her genetic counselor as she has CDH1 gene mutation

She underwent preoperative evaluation including EGD with random biopsies, no gross or microscopic evidence of cancer was seen.

Medical History

Morbid obesity (BMI 51 kg/m2)

PCOs

HTN

Depression

Hypothyroidism

Hyperlipidemia

The patient was then planned to

Laparoscopic total gastrectomy with Roux-en-Y esophagojejunostomy with D1 lymphadenectomy

Post-operative Course

POD #1 UGI showed no leak

Discharged after an uneventful postoperative recovery on POD #3 tolerating post-bariatric diet.

2 and 6-week clinic follow up – no nausea/vomiting/food intolerance

In Conclusion

Prophylactic laparoscopic total gastrectomy with D1 lymphadenectomy is a safe and feasible option for eliminating the risk of gastric cancer in CDH1 mutation

V369

Laparoscopic Sleeve Gastrectomy in a patient with agenesis of the left hemidiaphragm

C Hassan, LF Gonzalez Ciccarelli, A Gangemi, M Masrur, F Bianco, P Quadri, L Sanchez-Johnsen, P Giulianotti; University of Illinois at Chicago

Introduction: Diaphragm agenesis (DA) is the most severe form of a diaphragmatic defect and a rare occurrence in adults. DA has a high mortality ranging from 40 to 60% and is associated with lung and cardiac anomalies. We present a case of an asymptomatic 58-year-old female with an incidental intraoperative finding of a left hemi-diaphragm agenesis concurrently with a sleeve gastrectomy.

Methods and Results: 58-year-old female patient with a BMI of 40 kg/m2 and a past medical history of overactive thyroid and a bilateral total hip replacement. As part of the pre-surgical evaluation, a fluoroscopy and chest X-ray showed an elevation of the left hemi-diaphragm concurrent with a type II para-esophageal hernia of the stomach and stasis of contrast in the stomach. The patient elected to undergo a laparoscopic sleeve gastrectomy and a repair of para-esophageal hernia.

Diagnostic laparoscopy was performed with no visualization of a para-esophageal hernia. An incidental finding of a complete absence of the left hemi-diaphragm with an open communication between the abdomen and the left thorax was diagnosed. The stomach was mostly intrathoracic extending into the apex of the left chest. The pylorus was identified 10 cm to the left of the falciform ligament. Visualization and dissection of the short gastric were was extremely difficult due to the thoracic location of the spleen. Creation of pneumoperitoneum caused supraventricular tachycardia due to the pressure on the heart. There was no attempt to repair the defect due to the patient age, asymptomatic history and complexity of the repair. Standard sleeve gastrectomy was performed using a 40 French Bouguie. Intraoperative air-leak test was negative. Operative time was 116 minutes with an estimated blood loss of approximately 5 ml. Postoperative fluoroscopy showed no evidence of contrast extravasation. Patient was discharged tolerating a liquid diet on postoperative day one. Postoperative course was uncomplicated. Patient was doing well at one month follow up.

Conclusion: Sleeve gastrectomy surgery was performed with a patient who had left hemi-diaphragm agenesis and this procedure appeared to be safe and feasible. Even with a thorough preoperative evaluation, the diagnosis of asymptomatic DA is difficult task.

V370

A Unique Approach to Laparoscopic Sleeve Gastrectomy

Cynthia Weber, MD, Mujjahid Abbas, MD; University Hospitals of Cleveland

In our video we describe a unique approach to a laparoscopic sleeve gastrectomy that utilizes only 3 ports. The advantage of this technique is that the surgeon is able to perform the operation without the help of a skilled assistant. As such it can be performed in a community hospital setting without difficulty. This approach eliminates the need for the left upper quadrant port as well as the liver retractor; thus reducing the number of incisions, lowering postoperative pain, and reducing cost. The surgeon provides all of the necessary retraction and counteraction. At our institution we have safely and efficiently performed over 25 sleeve gastrectomies using this technique.

V371

Robotic Excision of Recurrent Lymph Node Metastasis from Gastric Gist

Sarah B Bryczkowski, MD 1, Stephen G Pereira, MD2; 1Hackensack Meridian Health, JFK Hospital, 2Hackensack University Medical Center

Introduction: Gastric gastrointestinal stromal tumor (GIST) is a common surgical diagnosis. Isolated lymph node metastasis is an exceedingly rare occurrence. The purpose of this case report was to document a case of a recurrent GIST metastatic to lymph nodes.

Methods: Retrospective chart review with video documentation. The daVinci Xi® robot was used. Apple iMovie for MacOS was used for video editing.

Results: Patient was a 47 year-old female eight years status post laparoscopic excision of 4.9 × 4.3 cm gastric GIST with low mitotic rate. She was treated with adjuvant Gleevec®. She underwent robotic excision of local recurrence four years ago. Pathology revealed an isolated recurrence in a gastrohepatic lymph node. Gastric tissue was negative for recurrence. Patient presented with a PET avid mass four years after the recurrent lymph node excision and eight years after index surgery. FNA revealed metastatic GIST. She went to the operating room for robotic excision of the recurrent GIST lymph node metastasis. Pathology was again consistent with GIST metastatic to lymph nodes.

Conclusion: Gastric GIST is a common surgical diagnosis. This case report is the first of its kind to document a gastric GIST with two times recurrent metastasis to lymph nodes despite ongoing treatment with Gleevec®. This case highlights the importance of oncology follow-up after excision of gastric GIST.

V372

Laparoscopic-assisted Percutaneous Endoscopic Gastrostomy (PEG) tube placement in patient with unsuccessful attempt of PEG

Usah Khrucharoen, Greg Sacks, Yijun Chen, Erik P Dutson; UCLA

In this video, we demonstrated a technique of laparoscopic-assisted PEG tube placement in patient with unsuccessful attempt of PEG due to air-filled loops of colon positioned between the stomach and anterior abdominal wall. In this case, patient had a history of recurrent embolic strokes and swallowing disorder with high risk of aspiration. In order to establish a long-term enteral nutrition support for the patient, laparoscopic-assisted PEG tube placement was performed following unsuccessful attempt of PEG. This technique allows the surgeon to perform a diagnostic laparoscopy in the peritoneal cavity as well as to ensure safe positioning of the gastrostomy site under videoscopic guidance and to avoid a potential intestinal injury. Upon insufflating the carbon dioxide into the peritoneal cavity to perform a diagnostic laparoscopy, the stomach was clearly visualized, and the procedure was carried out using the Ponsky pull technique. Operative time was 25 minutes. No intra-operative complications. The postoperative course was uneventful. Patient was successfully initiated a diet of tube feeding postoperatively.

V373

Robotic Assisted Morgagni Hernia Repair

Yalini Vigneswaran, Victoria Lyo, Stephanie Wood; OHSU

Here we present a case of a robotic assisted morgagni hernia repair with mesh. This is a 69 year old woman who presented with atypical symptoms of abdominal pain and dysphagia. Her work up included a normal endoscopy and esophagram. However due to her history of recurrent bronchitis further work up was done with a CT demonstrating transverse colon in her chest through a right diaphragmatic hernia. Her pulmonologist referred for repair due to her symptoms.

V374

Robot-Assisted Laparoscopic Subtotal Pancreatectomy/Splenectomy

Subhashini Ayloo, MD, MPH, Jacob Schwartzman, MD; Rutgers, New Jersey Medical School

Objective: To demonstrate the safety and feasibility of robot-assisted subtotal pancreatectomy and splenectomy in posterior pancreatic lesions.

Materials & Methods: A 43 year-old woman with symptoms of sweating, dizziness, hypoglycemia, is found on diagnostic imaging to have a large mass in the body/tail of pancreas with solid and cystic components.

This video showcases the fine technical details of a minimal invasive approach to subtotal pancreatectomy. The pancreas was exposed by transecting the gastrocolic ligament and retracting the stomach cranially with the 4th arm of the robot. The lesion was large, posteriorly located in the distal pancreas, extending inferiorly, and capsulated. The splenic flexure was taken down. About 2 cm proximal to the lesion, close to the portal vein, the pancreatic transection site was marked and a tunnel was created behind the pancreas starting from inferior border. The splenic artery is dissected and controlled. The pancreatic body was transected with an endo-GIA and medial to lateral dissection of the pancreas including splenectomy was performed. The specimen is extracted via a Pfannensteil incision.

Conclusions: Robot-assisted subtotal pancreatectomy and splenectomy is safe and feasible. The Da Vinci system provides a stable platform with 3-D visualization and improved ergonomics, which facilitate removal of large lesions that are located posteriorly and inferiorly on the pancreas.

Educational/Technical Points: The camera is positioned left mid-abdomen, with the left and right arms of the surgeon on either side. The robotic 4th arm is placed in a right lateral position, and a first assistant port is placed inferomedial to the surgeon’s left arm. The 4th arm of the robot has a multifunctional purpose in retracting the left lateral segment of liver and in retracting the stomach to expose the pancreas.

V377

Adult Presentation of an Incarcerated Bochdalek Hernia with Mesh Repair

Timothy Snow, DO, Marty Harnisch, MD, Dana Portenier, MD; Duke University Medical Center

This presentation will discuss a case of an incarcerated Bochdalek hernia in a 40-year-old adult female. The patient originally presented with her first time episode of left sided abdominal pain and shortness of breath after a transcontinental flight. On radiographic examination to rule out pulmonary embolism, a posterolateral diaphragmatic defect was observed containing a substantial amount of left and transverse colon within her left chest cavity. Urgent operative repair was pursued due to the patient’s severe pain and incarcerated colon, as there was a concern for ischemic bowel. The posterolateral defect was identified laparoscopically and the hernia contents were reduced. Due to location and concerns with tension, we elected to repair the defect using a synthetic mesh with biomaterial rather than a primary suture repair. Historically, adult diaphragmatic hernias have been repaired via laparotomy and primarily. This serves as an example of how as the skill set of general surgeons expands, laparoscopic mesh diaphragmatic hernia repair will become more commonplace in practice and in the literature.

V379

Laparoscopic distal pancreatectomy with splenectomy and left adrenalectomy

S Velmurugan, HOD of GI and Lap Surgery, R Villalan, B Kasi Viswanath, R Archana; kauvery hospital, Trichy, India

62 years female presented with left upper quadrant pain, back pain and postprandial fullness of 4 months duration. She had past medical history of Diabetes and Hypertension. Her abdominal examination was unremarkable. Her CT scan showed a 6 cm sized cystic lesion in the tail of pancreas close to splenic hilum. There was no associated lymphadenopathy. In addition, the CT showed a 2.5 cm sized adenoma in left adrenal gland.

She had an EUS guided FNAC from the cystic lesion. It was suggestive of mucinous lesion. Her endocrine work up showed that the adrenal adenoma was a non secreting lesion.

After informed consent, laparoscopic distal pancreatectomy with splenectomy and left adrenalectomy was performed.

Surgical procedure: One 10–12 mm port, one 10 mm port and two 5 mm ports used. Gastrocolic omentum divided with harmonic and lesser sac entered. Short gastric vessels divided. Inferior and superior border of pancreas defined. Retro- pancreatic tunnel created at distal body of pancreas medial to the lesion. As splenic vessels were going through the lesion, proceeded for splenectomy en bloc. Splenic artery and splenic vein ligated and clipped (hemolock) individually and divided. Pancreas divided with stapler using green cartridge at distal body leaving adequate margin from the lesion. Distal pancreatectomy with splenectomy done. Left adrenal identified and dissected. Left adrenal vein clipped and divided. Left adrenalectomy done. Stapled pancreatic end underrun with 2-0 PDS continuous suture. Drain kept. Specimen retrieved using a bag through pfannensteil incision.

Post operatively she had an uneventful recovery. She was discharged on the 6th post operative day. Her histology confirmed mucinous cystadenoma arising from the tail of pancreas and the adrenal lesion was a non functioning adenoma.

V380

Revision for Sleeve Gastrectomy Incisural Stenosis: Laparoscopic Seromyotomy

Yalini Vigneswaran, MD, MS, Sergio Toledo, Victoria Lyo, Andrea M Stroud, Farah Husain; Oregon Health & Science University

Management of patients with gastric stenosis after sleeve gastrectomy can be challenging due to varying efficaciousness of revisional therapies. Here we show video of a laparoscopic seromyotomy as treatment for sleeve stenosis. Important technique includes evaluating the sleeve with endoscopic insufflation when performing the myotomy. Relieving both the stenosis and the associated sleeve twisting that occurs with insufflation may be key in allowing for return to normal motility of the sleeve postoperatively. We believe laparoscopic seromyotomy of the incisural stenosis is a promising revisional technique for patients with sleeve gastrectomy stenosis that should be included in the algorithm prior to revision to gastric bypass. This technique is a low risk procedure and can allow for continued weight loss with sleeve gastrectomy despite initial failure.

V381

Laparascopic trans-gastric resection of submucosal mass

Jason E Kuhn, DO, Robert Cunningham, MD, Jon Gabrielsen, MD, Anthony Petrick, MD, David Parker, MD; Geisinger Medical Center

Geisinger Medical Center is presenting a video submission for a pre-pyloric submucosal mass unamenable to wedge resection without compromising the pylorus. Resection was performed in a laparscopic trans-gastric manner with endoscopic assistance for retrieval. The defect was closed primarily.

V382

Laparoscopic Hiatal Hernia Repair Following Ivor-Lewis Esophagectomy

Jarvis Walters, DO 1, Jeremy Holzmacher, MD1, Fred Brody, MD, FACS2; 1George Washington University Medical Center, 2Veterans Affairs Medical Center

During esophagectomy, the diaphragmatic hiatus is often widened to prevent an obstructed conduit, increasing the potential risk of hiatal hernia. This video depicts laparoscopic repair of a patient who presented with a Type IV hiatal hernia containing transverse colon seven months after Ivor-Lewis esophagectomy for adenocarcinoma.

V383

Laparoscopic Release of Median Arcuate Ligament

James Parker, MD1, Eric Forney, MD 1, Alex Sapp, MD1, Danny Vaughn, MD1, Eric Long, MD1, Gunnar Nelson2; 1Navicent Health Medical Center, 2Virginia Tech

Median arcuate ligament syndrome (AKA celiac artery compression syndrome) is a disorder that remains near the bottom of most differential diagnoses. There is still much to learn about the pathophysiology of this disorder, however as a diagnosis of exclusion, treatment of this syndrome via open or minimally invasive approach can be life-changing.

We present a 35 year old patient who underwent a laparoscopic release of the median arcuate ligament. She presented to clinic after 1 year of missed diagnoses, post-prandial abdominal pain, and significant (> 50 pound) 1 year weight loss. Dr. Danny Vaughn, a minimally invasive surgeon in Macon, GA, performed the surgery with exceptional results. Post-operatively, patient’s symptoms have completely resolved and she states that she can now enjoy life again.

We appreciate the opportunity to share our technique for exposure and division of the median arcuate ligament.

V384

Robotic Completion Cholecystectomy Following Laparoscopic Reconstitutive Subtotal Cholecystectomy

Donald M Moe, MD, Vance Y Sohn, MD; Madigan Army Medical Center

Subtotal cholecystectomy has long been described as a bail out or damage-control alternative to cholecystectomy when performing a difficult cholecystectomy. However, subtotal cholecystectomy requires completion cholecystectomy in 4–9% of cases. These reoperative surgeries are highly morbid and while there are case reports of minimally-invasive approaches they are generally completed with open surgery. Despite the open surgical approach, completion cholecystectomy following subtotal cholecystectomy has been reported with a common bile duct injury rate as high as 14%. We therefore describe our robotic approach to completion cholecystectomy following prior subtotal cholecystectomy as a safe and effective minimally-invasive approach.

V385

Robotic Repair of Recurrent Giant Hiatal Hernia with Nissen Fundoplication

Sharona B Ross, MD, FACS, Janelle D Spence, BA, Iswanto Sucandy, MD, Alexander S Rosemurgy, MD, FACS; Florida Hospital Tampa

Introduction: This is robotic reoperative giant hiatal hernia repair with loose Nissen fundoplication undertaken in a 75-year-old gentleman presented to the emergency department with epigastric pain, profound dysphagia, and a loss of appetite.

Methods and Procedures: Monemetry documented esophageal dysmotility and a CT scan corroborate the existence of the giant hiatal hernia.

Results: The operation was undertaken utilizing 6 ports, pneumoperitoneum was established, and under laparoscopic guidance, the liver was retracted. More than a half to three-quarters of the stomach was placed in the mediastinum. Carefully the dissection began toward the right crus into the mediastinum and slowly reduced the stomach back into the abdomen. Soon after, attention was turned to the short gastric vessels. Ultimately, the entire hiatal hernia was replaced into the peritoneal cavity and the hernia sac was divided and removed. 6–7 cm of esophagus was brought to the peritoneal cavity during mobilization. Reconstruction of the esophageal hiatus was undertaken using an Endo Stitch device with a V-Loc suture. The reconstruction was augmented by placing a suture on the ventral aspect of the defect to ensure a secure reconstruction that was tight, yet not too snug.

Conclusions: After the reconstruction was completed, the considerations for the fundoplication were made. The posterior fundus was sutured to the ventral and left side of the esophagus and then the anterior fundus was sutured to the ventral and right side of the esophagus. The posterior fundus was sutured to the ventral and left side of the esophagus and then the anterior fundus was sutured to the ventral and right side of the esophagus. Intraoperative EGD was undertaken which documented that the Nissen fundoplication was appropriately constructed at and above the GE junction. The posterior fundoplication was anchored to the esophagus and right crus and the anterior fundoplication was anchored to the left crus. The diaphragm was irrigated with dilute bupivacaine solution to minimize postoperative pain. The skin was approximated with interrupted vicryl sutures and sterile dressing. The patient tolerated the operation well with an uneventful postoperative course and was discharged the next morning.

V386

Laparoscopic repair of parahiatal hernia with falciform ligament flap and left triangular ligament flap hiatoplasty

Adam S Weltz, MD, Nolan Marks, Javaneh Jabbari, MHS, Alex Addo, MD, Zachary Sanford, MD, Adrian Park, MD, FACS; Anne Arundel Medical Center

Summary of Surgical Case: We discuss a 67 year-old male presenting with presumed large paraesophageal hernia. CT demonstrated presumed Type IV paraesophageal hernia with acute gastric volvulus. He was medically optimized and taken to the OR during hospitalization. Laparoscopy revealed a large diaphragmatic defect containing all of the patient’s stomach, much of the small bowel, and colon as well. These structures were reduced under tension. Their attachments to the diaphragm, omentum, and sac were taken down with a combination of sharp and blunt dissection. Further dissection included taking down the pars flaccida, allowing visualization of the right and left crura of the diaphragm. We then realized this was a large parahiatal hernia. Reinforcement of the repair was necessary as the left crus was flimsy. We mobilized the left triangular ligament at the level of the diaphragm and mobilized it laterally. We then closed the parahiatal defect. We incorporated the triangular ligament which we previously mobilized to buttress and reinforce this closure. With the parahiatal defect completely closed, there remained a sizable hiatal hernia defect. The esophagus was fully mobilized and it was necessary to mobilize the falciform ligament for posterior hiatoplasty in a retroesophageal position. Four of five points of fixation of the falciform ligament were in the retroesophagus. Final survey revealed complete repair of the parahiatal defect.

Educational/Technical Points: This presentation discusses the challenges associated with correctly diagnosing paraesophageal and parahiatal hernias. Utilization of the falciform ligament, when possible, is able to provide durable and lasting repair in the hands of an experienced hernia surgeon.

V387

Laparoscopic Median Arcuate Ligament Release: An Approach for Aberrant Celiac Artery Anatomy

Robert A Grossman, MD, Daniel Bergholz, BA; Mount Sinai Medical Center

Median Arcuate Ligament Syndrome is a rare disease, for which understanding of the pathophysiology remains in an early state. It predominantly affects younger women, and causes a constellation of symptoms consisting of post-prandial abdominal pain, nausea, emesis, and weight loss. Surgery appears to be the only method for relief of the symptoms associated with median arcuate ligament syndrome.

We present a case of a young woman with median arcuate ligament syndrome who underwent a laparoscopic median arcuate ligament release, but preoperatively was found to have an aberrant celiac artery structure. She had no formal celiac artery, but rather had a common hepatic and splenic artery directly taking off from the aorta; her left gastric artery arose from her common hepatic artery. She underwent a successful laparoscopic median arcuate ligament release, with full resolution of her symptoms.

V388

Laparoscopic removal of gastric stimulator and sleeve gastrectomy in a patient with gastroparesis

Adel Alhaj Saleh, MD, MRCS, Amir H Aryaie, MD, FACS; Texas Tech University Health Sciences Center

Case Background
  • A 44 year-old female with morbid obesity (BMI of 41 kg/m2) with multiple comorbidities including gastroparesis and history of gastric stimulator insertion.

  • She underwent multiple unsuccessful trials of medical weight loss.

  • After all the preoperative work up she was offered laparoscopic sleeve gastrectomy with removal of gastric stimulation device with the subcutaneous piece as well.

Medical and Surgical History
  • Morbid obesity

  • Depression

  • HTN

  • DM II

  • Gastroparesis

  • GERD

  • OSA

  • 14 abdominal procedures including repair of incisional hernia and insertion of gastric stimulator for gastroparesis

Preoperative EGD
  • Mild esophagitis and gastritis

  • Biopsies obtained showed no abnormalities

The patient was then planned to
  • Laparoscopic Removal of Gastric Stimulator and Sleeve Gastrectomy with injection of Botox at the pylorus

Post-operative Course
  • Discharged after an uneventful postoperative recovery tolerating bariatric diet.

  • 2 and 6-week clinic follow up – no nausea/vomiting/food intolerance

In Conclusion
  • Laparoscopic removal of gastric stimulator in obese patients and conversion to gastric sleeve is a feasible option

  • Injection of Botox at the pylorus will be helpful in gastric emptying and control of symptoms in perioperative period.

V389

Laparoscopic Repair of Giant Paraesophageal Hernia with Partial Gastrectomy for a Tumor

Andrey Vizhul, MD, FRCSC, Amer R Jarrar, MD, Amir Partovi, MD, FRCSC, Jean-Denis Yelle, MD, FRCSC, Amy Neville, MD, FRCSC, Joseph Mamazza, MD, FRCSC; The Ottawa Hospital, University of Ottawa

This is a case of an 81 year old female presenting to The Ottawa Hospital found to have a massive para-esophageal hernia and Gastrointestinal Stromal tumour of the stomach, this video outlines the technique for repair of this hernia and concurrent resection of gastric GIST.

V390

Robotic Whipple procedure in a patient with a replaced right hepatic artery

Julio Teixeira, MD, Andrew Godwin, MD, Dimitar Ranev, MD; Lenox Hill Hospital

This video shows a robotic-assisted Whipple procedure in a patient with a replaced right hepatic artery. The relevant steps of the procedure are narrated.

V391

Robotic Right Hemicolecotmy with Intracorporeal Anastomosis

Alberto Gonzalez, MD, Alvaro Mendez, MD, Arman Erkan, MD, Raymond Yap, MD, BmedSci, MsurgEd, FRACS, George Nassif, DO, FACS, John Rt Monson, MD, FACS, FRCS, FASCRS, Matthew Ross Albert, MD, FACS, FASCRS; Advent health

We present the case of a 61 yo male patient with past medical history of sigmoid resection for diverticulitis he presented with right lower quadrant pain and weight loss an 8 cm mass was identified in the cecum on a CT scan

After a previous colonoscopy and the identification of an ulcerated fungating mass involving the ileocecal valve cecal, which was unresectable by this means a biopsy was taken, and the diagnosis of an adenocarcinoma was made.

Patient was taken to the operating room to do a robotic assisted right hemicolecotmy

Previous trocar position, we begin by identifying the ileocolic pedicle and a medial to lateral approach was made, identifying the second portion of the duodenum then we skeletonized, then ligate and divide the ileocolic vessels separately, the superior mesenteric vein was identified distally.

We continued with the medial to lateral approach until the identification of the head of the pancreas after that we continued with a lateral mobilization of the right colon.

We then proceed to the identification, ligation and division of the right Brach of the middle colic artery with the robotic ultrasonic shears.

The transverse colon and the terminal ileum were prepared for division whit the robotic stapler and an intracorporeal laterolateral isoperistaltic ileocolonic anastomosis was fashioned, and the closure of the enerotomy on two layers was performed.

At this point the robot was undocked and the specimen was extracted of the abdominal cavity through a Pfannenstiel incision.

V392

Recurrent Hiatal Hernia with Dysphagia s/p Heller Myotomy with Dor Fundoplication

Robert Polak, MD, Theophilus Pham, BA, MBA, Adel Alhaj Saleh, MD, MRCS, Amir H Aryaie, MDFACS; Texas Tech University, Health Sciences Center

  • 48 y.o. female presented as a referral for possible achalasia s/p Heller Myotomy and Dor Fundoplication in 2001.

  • Initially helped for 3 years

  • Has since undergone 10 + endoscopic esophageal dilations

Symptoms:
  • difficulty eating/swallowing, early satiety, food regurgitation, chest pain, choking sensation at night

PMH:
  • DM, Achalasia, Hypothyroidism, Fibromyalgia, and frequent headaches

PSH:
  • Heller Myotomy with Dor Fundoplication, Cholecystectomy, Hysterectomy, Partial Thyroidectomy

  • Patient scheduled for EGD, Manometry, and UGI contrast study

UGI Findings:
  • Stenosis or achalasia at the GE Junction

  • Markedly dilated esophagus

EGD Findings:
  • Easy passage of scope through LES into the stomach

  • Markedly dilated esophagus, LES open, sliding hiatal hernia gastritis

  • Symptoms likely related to hiatal hernia

  • Integrated Relaxing Pressure < 15

  • Frequent failed peristalsis

  • Based on diagnostic workup patient offered a laparoscopic hiatal hernia revision and fundoplication takedown

Patient taken to OR and underwent:
  • Laparoscopic Hiatal Hernia Revision

  • Dor Fundoplication Takedown

  • Intraoperative EGD

  • Gastropexy

  • Patient doing well postoperatively

  • Symptoms are much improved

  • Able to tolerate PO diet without issue

Conclusion:
  • Dysphagia s/p Heller Myotomy needs to be thoroughly worked up including:

  • EGD, UGI, and manometry

  • Hiatal Hernia repair can significantly improve symptoms of dysphagia 2/2 esophageal dysmotility seen in patients with prior achalasia

  • Laparoscopic Hiatal Hernia Repair s/p prior Hiatal hernia repair with Dor Fundoplication is feasible

V393

Laparoscopic Conversion of a Gastro-gastrostomy to a Roux-en-Y Gastric Bypass

Aqeel Ashraf, BMedSc, BMBCh 1, Haytham Alkhayat, FACS2, Khalid Alsharaf, FACS2, Mohammad Jamal, MBChBHons, MEd, FRCSC, FACS, FASMBS3; 1McGill University, Resident in General Surgery, 2Mubarak Al-Kabeer Hospital, Kuwait, 3Kuwait University, Faculty of Medicine

Laparoscopic sleeve gastrectomy (LSG) is gaining prominence as it became the most frequent bariatric procedure performed. In 2015, LSG accounted for more than 50 percent of all bariatric procedures carried out in the United States.

Post sleeve gastrectomy stenosis is a rather uncommon complication that can present acutely or chronically. Etiologies of such entity can be functional, due to edema or a hematoma at the staple line for instance, or related to the surgical technique. Management can be conservative or via interventions including, endoscopic balloon dilatation, seromyotomy and definitely through a Roux-en-Y gastric bypass.

In this video, we present a rather complicated case of a patient who developed a stricture post laparoscopic sleeve gastrectomy. This was managed with a gastric sermyotomy and was complicated with perforation, in which a gastro-gastrostomy was performed. The patient then developed severe acid reflux as a result of narrowing at the site of the gastro-gastrostomy. This video outlines a definitive management of such complicated case with a laparoscopic Roux-en-Y gastric bypass.

V394

Laparoscopic vs Robotic Splenic Cyst Excision

Marcoandrea Giorgi, MD, Aevan Mclaughlin, MD, Todd Stafford, MD, Sivamainthan Vithiananthan, MD; Brown University - Rhode Island Hospital

We illustrate in this video the techniques for robotic and laparoscopic splenic cyst excision. Both patients underwent pre operative vaccination. The first patient was a 55 years old female with chronic lumbar pain who was found to have a large anterior splenic cyst which was excised using the robotic technique. The second patient was a 28 years old male with left sided abdominal and chest pain. CT scan showed a posterior large splenic cyst which was excised laparoscopically after the spleen was mobilized

V395

Laparoscopic repair of Paraesophageal Hernia

Alyssa Bellini, BS, Federico Serrot, MD, Maria Fonseca Mora, Cristian Milla Matute, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Laparoscopic repair of an incarcerated Paraesophageal hernia

Acute incarceration of hiatal hernias is rare. Laparoscopic paraesophageal hernia repair (LPEHR) is a feasible surgical option with low overall, recurrence, mortality and morbidity. We present the case of a 31-year-old woman, with a history of nausea, vomiting, and epigastric pain, with a chronically incarcerated hiatal hernia diagnosed on CT scan. She underwent LPEHR with concomitant Nissen fundoplication with resolution of her symptoms and no complications.

V396

Management of Cascade Stomach in a Previously Operated Bochdalek Hernia with Tension Gastrothorax

Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Khushboo N Kadakia, MBBS, Girish D Bakhshi, MSMRCSDNB, FMAS, FIAGES, FAIS, FICS, FBMS, Amol N Wagh, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Shekhar A Jadhav, MS, FMAS, Priyanka M Saha, MBBS, Shivang Shukla, MBBS; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Cascade stomach is rare. Very few cases are reported in literature. Literature search reveals laparoscopic management of cascade stomach by Nissen’s Fundoplication, sleeve resection, gastropexy etc. However, there are no guidelines regarding procedure of choice for management of cascade stomach. This case was managed laparoscopically by adhesiolyses, gastropexy and gastrojejunostomy, which has not been reported yet.

The case highlights the rare entity of cascade stomach, various mechanisms for development of cascade stomach, symptomatology, diagnoses and the possible management options for the same.

V397

A Case of the Redundus Fundus

Anne P Ehlers, MD, MPH, Saurabh Khandelwal, MD, Andrew S Wright, MD, Judy Y Chen-Meekin, MD; University of Washington

The patient is a 37-year-old woman who had previously undergone an open sleeve gastrectomy at another institution. Several years after her initial operation, she had a BMI of 40 and was experiencing symptoms of heartburn and reflux. Pre-operative EGD showed esophagitis and upper GI showed a small hiatal hernia as well as an enlarged fundus. Given her symptoms as well as her BMI of 40, we recommended revision of her bypass to Roux-en-Y gastric bypass. We performed intraoperative endoscopy and located a significant amount of redundant fundus that was likely contributing to her symptoms. To address this, we resected the excessive fundus to construct a more optimally sized pouch. From this case we learned that inadequate mobilization of the stomach can lead to a failure to recognized the amount of redundant fundus resulting in a staple line far away from the GE junction and angle of His. This was a likely contributor to the patient’s esophagitis and reflux. Data from the ASMBS indicates the increased incidence of sleeve gastrectomy. In 2011, approximately 18% of all bariatric surgeries were sleeves, compared to nearly 60% in 2017. At the same time, revisional surgery has increased as well, from 6% in 2011 to 24% in 2017. Given the popularity of this procedure as well as the increase in revisions, it is imperative that surgeons performing this operation understand the importance of an adequate dissection.

V398

eTEP TAR for Lumbar Hernia

Sarfaraz Baig; Belle Vue Clinic

Like all atypically sited hernias, lumbar hernias face the challenge due to proximity to the bony landmarks which makes it difficult to create adequate space for mesh placement through conventional methods. The mesh fixation is a challenge as well in the atypically sited hernias in repairs like onlay or intraperitoneal onlay.

The introduction of eTEP technique by Dr Jorge Daes and its adoption in lumbar hernias by Dr Igor Belyansky has made it possible to create a large space in the pretransversalis plane and has done away with the problem of fixations.

We have found the eTEP technique particularly useful for these atypically sited hernias such as lumbar, subcostal, and subxiphoid hernias.

In this video, we present one such video of lumbar hernia repair through eTEP technique.

V399

Robotic Resection of Gastric Gastrointestinal Stromal Tumor

Miranda Lin, BS 1, Heather Sinner, MD1, Owen Pyke, MD, MPH, MBA2, Georgios V Georgakis, MD, PhD2, Chantae Sullivan-Pyke, MD3, Aaron R Sasson, MD2, Mark Talamini, MD, MBA2, Joseph Kim, MD1; 1University of Kentucky, 2Stony Brook University Hospital, 3University of Pennsylvania

Gastrointestinal stromal tumors (GIST) commonly arise in the stomach or small intestine. Depending on the size, a GIST may result in bleeding into the gastrointestinal tract and hematemesis, which may then require surgery to remove the tumor. Minimally invasive techniques have become favorable to open gastrectomy for GIST resection because they result in decreased postoperative pain, shorter hospital stay, and quicker recovery. While laparoscopic techniques have become more common for GIST resection, few studies have documented the success of robotic resection. This video presents the case of a 49yo male with a gastric mass, consistent with GIST as seen on upper endoscopy, arising from the fundus and extending to the cardia of the stomach. Due to the abruptness of the bleeding and risk for rebleeding, the patient was brought to the operating room for robotic resection. The Da Vinci Si platform was used for this procedure. Invasion of nearby lymph nodes and metastatic disease were not identified. Wedge resection was favored over partial gastrectomy and proximal gastrectomy to minimize the amount of resected tissue while obtaining negative margins. Monopolar cautery with hook was used to open the anterior aspect of the stomach and an Endoscopic GIA stapler was used to resect the tumor and surrounding normal tissue. The gastrectomy was closed along a longitudinal plane using robotic suturing in two layers with 3-0 PDS running suture. Suturing was preferred over linear stapling devices to prevent potentially narrowing the gastroesophageal junction. A LAPRA-TY was placed at the ends of the suture line. After this procedure, patients are typically discharged home on postoperative day #4. While patients are at risk for the same postoperative complications seen with open gastrectomy, we have never had an anastomotic leak with wedge resection and have had zero mortality with this procedure over the last decade.

V400

Takedown of Nissen Fundoplication

Consandre P Romain, MD, Benjamin Biteman, MD; Mercy Health Youngstown

31 y/o who was seen 6 months prior with gastroesophageal reflux disease refractory today medical therapy. He had work up including EGD, esophagram, manometry which ruled out motility disorders and pH monitoring. He underwent a Nissen fundoplication. He had persistent dysphagia postoperatively with EGD and esophagram without evidence of obstruction. He did not respond to dilation and after long discussion with the patient who had frequent visits with complaints, decision was made to proceed with takedown of fundoplication.

V401

Porcelain Gallbladder Adherent to Proximal Bile Duct; Robotic Cholecystectomy Guided by Indocyanine Green Cholangiography

Adel Alhaj Saleh, MD, MRCS, Edwin Onkendi, MBChB; Texas Tech University Health Sciences Center

A 52 year-old female presented to an outside institution with 1 year history of right upper abdominal pain

She also had unintentional weight loss.

CT scan with contrast showed a porcelain gall bladder

A laparoscopic cholecystectomy was attempted at that institution.

Intraoperatively, the gallbladder wall was hard and was thought to be adherent to the common bile duct.

Due to the risk of injury to the common bile duct, the surgeon at the outside institution appropriately aborted the procedure and referred the patient to our center, to be managed by a hepatobiliary surgeon.

The patient was taken to OR for robotic cholecystectomy under indocyaninegreen cholangiography guidance

Indocyaninegreen cholangiography aided better visualization of the bile duct and guided dissection of the gallbladder off of it.

The Patient had an uneventful postoperative course

Gradually advanced to full diet and was discharged on POD #1

Was seen in the clinic 2 weeks after the procedure and had no issues.

The pathology report was benign.

Robotic approach for cholecystectomy of porcelain gallbladder adherent to bile duct aided by indocyaninegreen cholangiography was especially useful and safe in this case to prevent bile duct injury.

Also the ability to retract and achieve exposure without need to grasp the hard porcelain gallbladder made the robotic approach best as opposed to laparoscopic approach.

V402

Robot Assisted Sugarbaker repair of a large parastomal hernia

Gabriela M Aguiluz, MD, Michael Cudworth, MD, Roberto Bustos, MD, Mario Masrur, MD; University of Illinois Hospital & Health Sciences System

A 45-year-old female patient with obesity and history of Crohn’s disease and fecal incontinence that underwent a robot-assisted abdominoperineal resection with end colostomy. Three months postoperatively, the patient complained of pain and bulging around the stoma. A CT scan of the abdomen and pelvis showed a large parastomal hernia with small bowel loops in the hernia sac. Decision was made to perform a robot-assisted parastomal hernia repair.

Sugarbaker technique was used to repair the hernia due to reported lower recurrence rates as compared to the laparoscopic Keyhole technique. Procedure commenced with lysis of adhesions, reduction of the hernia sac contents, the hernia defect was then closed primarily utilizing a barbed suture, followed with placement of a large knitted biological mesh, secured in place with interrupted vicryl sutures. After which, the edges were secured with an additional running barbed suture, with the ostomy limb displaced laterally without tension. The procedure was carried out with no complications. The operative time was 191 min and estimated blood loss of 30 cc.

On postoperative day 3, the patient developed ileus which resolved with conservative management. The patient was discharged on postoperative day 8. At 3 month follow up, the patient was doing well with no evidence of recurrence.

Utilization of the robotic platform provides increased surgical dexterity, highly precise suturing and more optimal surgical visualization as compared to traditional laparoscopy, which facilitates repair of large parastomal hernias in a minimally invasive fashion, including easier primary hernia repair and mesh fixation.

V403

Laparoscopic approach to Median Arcuate ligament syndrome, hiatal hernia repair and inguinal hernia repair

Maria Fonseca Mora, MD, Cristian Milla Matute, MD, Rene Aleman, MD, Armando Rosales, MD, Emanuele Lo Menzo, MD, Samuel Szomstein, MD, FACS, FASMBS, Raul Rosenthal, MD, FACS, FASMBS; Cleveland Clinic Florida

Median arcuate ligament syndrome is a rare entity and its diagnosis might be challenging. Associations between MALS and Hiatal hernia had been reported and attributed to the different anatomical distribution of muscular and tendinous structures. We present the case of a 63-year old male with a long-standing history of postprandial abdominal pain and diagnosed with median arcuate ligament syndrome, type I hiatal hernia and symptomatic inguinal hernia. Careful laparoscopic dissection of the median arcuate ligament and closure of the hiatal defect were performed in addition to transabdominal preperitoneal inguinal hernia repair. The patient was discharged with full resolution of symptoms and no further complications.

V404

Novel Smooth Muscle Stimulation Technology for Ureter Identification During Abdominopelvic Operations

John J Nguyen-Lee, MD 1, Albert Y Huang, MD2, Shawn M Purnell, MD1, Brian J Dunkin, MD, FACS3; 1Houston Methodist, 2Allotrope Medical Inc., 3Houston Methodist Institute for Technology, Innovation & Education

With surgical approaches and technologies becoming less and less invasive, there is greater reliance on visual identification of critical tissue structures due to loss of haptic feedback. During abdominopelvic operations, identification of the ureter is a critical step of the procedure both to prevent injury as well as to serve as a landmark during dissections into the retroperitoneum. Current techniques rely on pre-operative stent placements, fluorescent injections as well as Urology consults, which can require additional operating time and increase surgeon stress.

Presented in this demonstration is a novel smooth muscle stimulation technology that elicits ureter peristalsis allowing instantaneous identification as well as the ability to visually trace the path of the ureter. The electrical impulse is both novel and specific for smooth muscle structures, and it reliably and repeatably generates ureteric contractions. Designed as a low-cost disposable laparoscopic instrument, it can be held by the surgeon and fits seamlessly into the surgical workflow.

Application of this technology during colonic resections, gynecologic procedures as well as other procedures near the ureter can speed ureter identification, decrease dissection (and the associated injury risks), and minimize the need for stent placement and consults. As such, this system can increase the safety profile of an operation, decrease costs, increase surgical efficiency, and provide a documentable way of ensuring ureter protection.

V405

Laparoscopic excision of intra abdominal esophageal duplication cyst- A rarity

Girish D Bakhshi, MS, MRCS, DNB, FCPS, MNAMS, FMAS, FIAGES, Jai Rathore, MBBS, Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS, Amol N Wagh, FMAS, FIAGES, FAIS, FICS, FBMS, Shraddha D Gangawane, MS, Ruchira Bhattacharya, MBBS; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Esophageal duplication cysts (EDC) are congenital anomalies of foregut origin. Supposed to occur at gastrulation stage of embryonic development. Etiopathogenesis is unclear.

Incidence is 1 in 8200 individuals. Intraabdominal EDC are extremely rare. Symptoms include cough, dysphagia, substernal pain and regurgitation.

CECT proves to be a useful diagnostic tool but histopathological examination is confirmatory.

Treatment is surgical excision in which minimally invasive surgery is now the treatment of choice.

Intraoperative ICG aids in safe dissection and excision of cyst and prevents damage to major vessels. This presentation highlights technique of laparoscopic excision of this rare entity.

V406

Laparoscopic sub-total colectomy with ileorectal anastomosis in complicated Crohn’s disease.

Irbaz Hameed, MD, Emre Gorgun, MD; Cleveland Clinic

In patients with extensive inflammatory bowel disease, a laparoscopic approach is not commonly used due to the limitations of the technique and risk of major complications. In this video, we present a patient with complicated crohn’s disease who underwent laparoscopic subtotal colectomy with ileorectal anastomosis. The patient is a 24-year old man with severe Crohn’s disease for several years who presented with persistent left sided abdominal pain. He had no prior bowel resection and was refractory to medical treatment. CT scan revealed strictures in the descending colon, as well as in the terminal ileum and presence of an entero-colonic fistula. As evident from the CT scans and subsequent intraoperative findings, the colon was found to be extensively diseased, and decision was taken to resect the entire colon. The surgery begun with a careful assessment of problems and small jejunal loops were found to be attached to the strictured segment. These were at first, sharply taken down and mobilized. Subtotal colectomy was performed laparoscopically with creation of end-to-end ileorectal stapled anastomosis and proximal diverting loop ileostomy. The patient recovered completely from surgery with no immediate or post-procedural complications. Laparoscopic surgery is less invasive and effective for the management of complicated inflammatory bowel disease. The technique can be utilized for extensive bowel resection and repair with minimal post-operative scarring and faster recovery.

V407

Right sided robotic assisted thoracic duct ligation following Nissen fundoplication

Baongoc Nasri, MD, PhD, Raja Mahidhara, MD, Vijay Nuthakki, MD, Anthony Ascioti, MD; St. Vincent Indianapolis

Introduction: Postoperative chylothorax is a well described complication after thoracic operations. Chylothorax is a rare complication of paraesophageal hernia with Nissen fundoplication. Extensive intrathoracic dissection of retroesophageal window in paraesophageal hernia repair can expose the thoracic duct to injury. Robotic assisted thoracic duct ligation is an attractive option for definitive management.

Purpose: Case report of right sided robotic assisted thoracic duct ligation following Nissen fundoplication.

Materials and Methods: This is a 76-year-old female underwent Nissen fundoplication for incarcerated paraesophageal hernia repair complicated by persistent chylothorax at outside hospital. She underwent right sided robotic assisted thoracic duct ligation because she failed conservative management for 30 days. The patient was placed in the left lateral decubitus position with, right lung isolation. 3 port technique was utilized. First port was placed at fifth interspace anterior axillary line for camera. Bipolar was docked at arm 3, in the third interspace in the anterior axillary line and cardier forcep was docked at arm 1 in the eighth posterior axillary line. Assistant port was placed between the third interspace port and the fifth interspace port. We began by taking down the inferior pulmonary ligament, incised the mediastinal pleura overlying the esophagus. We identified the vertebral body and there was a lot of fluctuance of chylous fluid coming from that area. Thoracic duct and multiple accessory ducts were identified. All were clipped with Hem-o-lock. We did a standard talcum pleurodesis using 4 grams of talcum powder insufflated into the chest. A 24-French chest tube was placed.

Results: She started clear liquid diet, wean off Octreotide on POD 2. Octreotide and TPN was stopped on POD 3. She tolerated soft diet. She received 1 PRBC for low Hb on POD 5. She had intermittent elevated chest tube output possible from bleeding after decortication versus loculated old pleural effusion. However chest tube output gradually slowed down, triglyceride level was low 33 mg\dl. Chest tube was removed on POD 9. She discharged home in good condition after her medical issues resolved on POD 21.

Conclusion: Thoracic duct injury is a rare complication of Nissen fundoplication. Right sided thoracoscopy is a feasible approach for definitive management for thoracic duct injury. Robotic platform enhances visibility in limited space, facilitates complex dissection even at delayed presentation.

V408

Robotic repair of incarcerated traumatic diaphragmatic hernia

Sara E Holden, MD, Jeffrey A Blatnik, MD; Washington University School of Medicine

This video depicts a 50-year-old female with a symptomatic incarcerated left hemidiaphragmatic hernia. This was caused by a traumatic injury during a prior nephrectomy complicated by an inferior vena cava injury requiring emergent laparotomy and graft reconstruction. Her preoperative symptoms were upper abdominal pain, shoulder pain, early satiety, nausea, and vomiting. Cross-sectional imaging confirmed a left hemidiaphragmatic defect with herniation of the proximal stomach into the hemithorax. The plan was to proceed with minimally invasive reduction of stomach with hernia repair.

Intraoperatively, pneumoperitoneum was established with the Veress needle at the umbilicus. Four robotic trochars were placed at the umbilicus, left subcostal, and right/left lateral abdomen. The robot was docked. Initial inspection demonstrated a large diaphragmatic hernia located just lateral to the left crus, posterior to the left lateral lobe of the liver. The liver and spleen were densely adherent to the diaphragmatic borders of the hernia. A moderate portion of the stomach and omentum were herniated through the defect and incarcerated, requiring meticulous adhesiolysis to fully reduce the contents out of the chest and create appropriate space for the mesh along the diaphragm. The defect measured 4 × 5 cm, and the intraperitoneal space was in continuity with the left pleural space requiring chest tube placement at the completion of the procedure. The hernia defect was closed primarily with interrupted 0-Ethibond sutures and reinforced with a 7 × 11 cm piece of coated polypropylene mesh, covering the defect well in all directions.

The patient was seen 3-weeks post-operatively and recovering well, with improvement in all of her pre-operative symptoms.

V409

Hiatal Hernia Repair and Fundoplication Using the Gastric Remnant Following Gastric Bypass

Jana Chtchetinin, MD, Dana Portenier, MD, Marcus Darrabie, MD; Duke University Medical Center

Hiatal hernia in a patient who has previously undergone roux-en-y gastric bypass can be a challenging problem. The gastric pouch is not amenable to fundoplication, and therefore can make addressing the problem of reflux difficult. Here, we describe a case in which we used the gastric remnant for fundoplication around the gastric pouch to treat a patient’s hiatal hernia and reflux symptoms successfully.

V410

Laparoscopic Conversion of Gastric Plication to Roux-en-Y Gastric Bypass

Aqeel Ashraf, BmedSc, BMBCh 1, Haytham Alkhayat, FACS2, Khalid Alsharaf, FACS2, Mohammad Jamal, MBChBHons, MEd, FRCSC, FACS, FASMBS3; 1McGill University, Resident in General Surgery, 2Mubarak Al-Kabeer Hospital, Kuwait., 3Kuwait University, Faculty of Medicine

Due to the growing prevalence of morbid obesity, procedures for weight loss, whether restrictive or malabsorptive, are of great importance. In addition, as a result of insufficient weight loss from such procedures, the need for revisional surgeries is also growing. Revisional bariatric surgeries are technically demanding, and when compared to the primary weight loss procedures, they carry a higher risk of complications.

In this video, we present the laparoscopic conversion of a gastric plication, which is still considered an investigational procedure, to a Roux-en-Y gastric bypass. The indication, pre-operative workup and post-operative course are outlined.

V411

Use of Indocyanine green fluorescence imaging in upper gastroesophageal cancer resections

S Valanci, MD, J Fiore, PhD, L Lee, MD, L Feldman, MD, G Fried, MD, LE Ferri, MD, C Mueller, MD; McGill University

Indocianyne green (ICG) was introduced to laparoscopic surgery to improve anatomical information, it may be ussed for perfusion assessment, lymph node mapping or vascular and biliary anatomy. We present 4 cases of upper GI cancer, in the first 3 cases perfusion assessment with ICG was performed, demonstrating good and poor blood flow. The last case is a sentinel lymph node mapping using ICG for early gastric cancer. ICG injection with near infrared fluorescence imaging may aid surgical decision making in upper GI cancer resections.

V412

An early experience with eTEP Rives Stoppa

Ajay H Bhandarwar, MS, FMAS, FIAGES, FAIS, FICS, FBMS, FLCS, Eham L Arora, MS, DNB, Ramesh Punjani, MS, FIAGES, FICS, Amol N Wagh, MS, FMAS, FIAGES, FAIS, FICS, FBMS, FLCS, Shekhar Jadhav, MS, FMAS, Jalbaji More, MS, Amarjeet E Tandur, MS, Priyanka Saha, MBBS; Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai, India

Minimal invasive Rives Stoppa is considered as one of the complex hernia surgeries. In view of many inherent perils & complications, step by step management protocol is the key for safe & successful outcome. The awareness about MIS Rives Stoppa & eTAR is crucial to tailor a particular procedure as & when needed. This presentation highlights step by step approach for minimal invasive eTEP Rives Stoppa technique. This video also highlights PRS bridging with an absorbable mesh endoscopically which was technically demanding in a tight retro-rectus space. The patient had an uneventful post-operative course.

V413

Laparoscopic multi-organ reduction and primary repair of a giant hiatal hernia

Imran Aziz, Dilip Dan, MBBS, FACS, ABS, RECERTIFIED Professor; University of the West Indies

Introduction: Giant Hiatal hernias are rare occurrences and are equally rare causes of acute pancreatitis.

Methods and Procedures: A 57-year-old male with a past history of having an asymptomatic hiatal hernia for 30 years presents with symptoms and signs of mild acute pancreatitis. The patient was managed conservatively and was incidentally found to also have a giant hiatal hernia. Subsequent radiological imaging discovered a 7.7 cm × 9.0 cm large focal defect on the posterior aspect of the diaphragm, through which the entire stomach protrudes along with loops of small bowel, the transverse colon, omentum and the tail of the pancreas. No other causes were found to be causative of this patient’s pancreatitis in keeping with other case reports of Giant Hiatal hernias being implicated as a rare cause for acute pancreatitis.

Results: This patient underwent a laparoscopic reduction of the visceral contents and repair of the giant hiatal hernia. The video presented demonstrates the sequential reduction of the organs protruding through the hiatus followed by a primary repair. The patient went on to have an uneventful recovery and six months’ post repair continues to show no evidence of recurrence.

Conclusion: Giant Hiatal hernias involving the small bowel, stomach, transverse colon, omentum and the pancreas are amenable to laparoscopic primary repair.

V414

Laparoscopic Dormía Basket retrieval by choledochotomy plus primary closure using three ports: Case report of a hooked Dormía Basket during ERCP

Daniel Gomez, MD, FACS1, Luis F Cabrera, General Surgeon2, Andres Mendoza, General Surgeon2, Ricardo Villareal2, Mauricio Pedraza 2, Jean Pulido2, Eric Vinck, MD2, Sebastian Sanchez2; 1CPO, 2Bosque University

Introduction: ERCP with endoscopic sphincterotomy (EN) and stone extraction with Dormia Basket or balloon catheters, is the current approach for the management of choledocholithiasis. Recently, there have been some uncommon complications associated with these conventional techniques, such as the retention of the Dormia basket inside the bile ducts or it´s rupture, mainly related to difficult stones (giant, multiple or intrahepatics stones), different to our case in which the Dormia Basket got hooked to the left hepatic duct during ERCP by a mechanism different to a stone impacted in the lumen of the duct.

Methods: We present a video of a rare case managed with a laparoscopic approach using three ports to perform a biliary duct exploration plus Dormia Basket retrieval whit primary closure of the CBD.

Results: The case was carried out completely laparoscopically with a time of 45 min, an estimated blood loss of 10 cc, oral intake at the same day of surgery, the patient was discharged at 72 hours and in early follow up we didn´t registered a bile leak.

Conclusions: The laparoscopic approach for the management of this uncommon ERCP related complications, such as the one presented in our video using three ports for the CBD exploration and the subsequent primary closure, is a feasible and safe option as demonstrated in this case.

V415

A Novel Laparoscopic Approach for Introduction of Magnetic Compression Anastomotic (Magnamosis) Rings

Vamsi K Aribindi, MD 1, Veeshal H Patel, MD2, Scott V Weiner, MD3, Phillip Kim, MD, MBA4, Rebecca C Gologorsky, MD3, Oliver A Guevarra3, Carissa E Chu, MD3, Marshall L Stoller, MD3, Harrison R Michael, MD3; 1Baylor College of Medicine; University of California, San Francisco, 2University of Washington; University of California, San Francisco, 3University of California, San Francisco, 4New York Presbyterian Hospital Columbia University Medical Center; University of California, San Francisco

In this video, laparoscopic delivery of magnets for intestinal anastomosis is shown. The operation is an ileal conduit performed for neurogenic bladder secondary to paralysis. The plan was for a laparoscopic bowel resection and anastomosis using the magnets, followed by planned conversion to open to finish the operation. First, the right colon is mobilized medially in preparation for the ileal conduit. Then, a portion of the ileum to be used is identified. This portion is marked and secured at either end by vessel loops. An enterotomy is made at the distal end of the marked portion of the ileum and the magnets are introduced, one at a time. They are first brought into the body through a laparoscopic port hole with the port removed, and then placed into the bowel and milked into place. The portion of ileum was then stapled off, and the site of the enterotomy was also stapled off and removed. A technical mishap with the magnets coming together prematurely was then corrected, and the bowel is slid into correct alignment for the anastamosis. However, once the anastomosis was completed and magnets positioned, due to the abnormally small caliber of the patient’s bowel relative to the magnets and known paralytic ileus, the decision was made to convert to a stapled anastomoses. Nonetheless, the technical success of the procedure is shown here.

V416

Laparoscopic repair of incarcerated paraesophageal hernia involving the Gastric pouch, Roux limb, and portion of the Remnant Stomach with mesenteroaxial volvulus

Erik Madden, MD, Patrick Roush, MD, Andrew Wheeler, MD, Rama Ganga, MD; University of Missouri

Roux-en-Y gastric bypass is a long-standing option for management of morbid obesity but can present unique surgical challenges. This video highlights the presentation and management of an unusual complication: an acute paraesophageal hernia containing the gastric pouch & roux limb, and a portion of the remnant stomach with a mesenteroaxial volvulus.

The patient is a 42-year-old woman with history of Roux-en-Y gastric bypass five years prior. She presented with acute epigastric pain, nausea and vomiting. Imaging and subsequent laparoscopy revealed this unique combination of herniated structures. To our knowledge, this is the first reported case detailing this specific combination of findings. The video submitted demonstrates the laparoscopic reduction and repair and highlights a surgical option for management of this rare complication.

Notes

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

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