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27th International Congress of the European Association for Endoscopic Surgery (EAES) Sevilla, Spain, 12–15 June 2019




G.S. Abis 1, H.B.A.C. Stockmann2, H.J. Bonjer1, N. van Veenendaal1, M.L.M. van Doorn-Schepens3, A.E. Budding3, J.A. Wilschut4, M. van Egmond1, S.J. Oosterling2, 1Surgery, VUMC, AMSTERDAM, The Netherlands; 2Surgery, Spaarne Gasthuis, HAARLEM, The Netherlands; 3Microbiology, VUMC, AMSTERDAM, The Netherlands; 4Statistics, VUMC, AMSTERDAM, The Netherlands

Aims: Infectious complications and anastomotic leakage affect approximately 30% of patients after colorectal cancer surgery. The aim of this multicenter randomized trial was to investigate whether selective decontamination of the digestive tract (SDD) reduces these complications of elective colorectal cancer surgery.

Methods: The effectiveness of SDD was evaluated in a multicenter, open-label, randomised clinical trial in 6 centres in The Netherlands. Patients with colorectal cancer scheduled for elective curative surgery with a primary anastomosis were eligible.

Oral colistin, tobramycin, and amphotericin B were administered to the SDD group to decontaminate the digestive tract. Both groups received intravenous cefazoline and metronidazole for peri-operative prophylaxis. Mechanical bowel preparation was given for left sided colectomies, sigmoid and anterior resections. Anastomotic leakage was the primary outcome while infectious complications and mortality were secondary outcomes. This trial was registered with number NCT01740947.

Results: In total, 228 patients were randomized to the SDD group and 227 to the control group until the trial was stopped after interim-analysis demonstrated that superiority was no longer attainable. Effective SDD was confirmed by interspace DNA profiling analysis of rectal swabs. Anastomotic leakage was observed in 14 patients (6.1%) in the SDD group and in 22 patients (9.6%) in the control group (odds ratio) [OR 0.61 (0.30–1.22)]. In the SDD group, fewer patients had one or more infectious complications than in the control group (14.9% (n = 34) versus 26.9% (n = 61), [OR 0.48 (0.30–0.76)]. On multivariable analysis, SDD reduced infectious complications OR 0.472 (0.294–0.755).

Conclusion: SDD reduces infectious complications after colorectal cancer resection but did not significantly reduce anastomotic leakage in this trial.



A. Rabal Fueyo1, J. Bollo Rodriguez 1, C. Martinez Sánchez2, M. Solans Solerdelcoll1, N. de la Fuente1, D. Sacoto1, E.M. Targarona Soler1 1General Surgery, Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain; 2Colorectal Surgery, Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

Aims: There are several studies that demonstrate the superiority of the intracorporeal (IA) vs extracorporeal (EA) anastomosis. But most reports are non-randomized, retrospective, and carried out in heterogeneous groups of patients, which might induce patient selection bias.

Methods: We present the first randomized controlled trial, designed to evaluate the two interventions with thorough measurements of the postoperative variables and complications to improve the evaluation of the surgical technique. The primary endpoint is to compare the length of hospital stay. The secondary endpoints were the comparison of intraoperative technical and postoperative clinical events.

We included patients aged = 18 years old referred only for right colon cancer and requiring an elective laparoscopic right hemicolectomy.

Results: 140 patients were randomized. The characteristics of the patients were equivalent between groups. Surgical time was longer in IA vs EA (149 ± 27 vs 123 ± 36 min). The length of resected colon was longer in IA vs EA (25.2 ± 5.7 vs 22.6 ± 7.8 cm) with similar number of lymph nodes (19.6 ± 6 vs 19.1 ± 7).The length of wound was shorter in IA (6.7 ± 1.2 vs 8.7 ± 1.4 cm). The postoperative analgesia was lower in IA (39 ± 24.3 vs. 53 vs. 26), and the pain score was lower according to the EVA scale in group IA (1.8 ± 1.8 vs 2.9 ± 2.2).

The recovery of digestive functionality was earlier in IA (2.3 vs 3.3 days) with lower incidence of paralytic ileus (13% vs 30%). Postoperative complications according to Clavien Dindo classification were lower in IA: grade I (10% vs 27%); grade II (18% vs 35%); grade III (1.4% vs. 7.2%).

Incidence of anastomotic leak was lower in IA (4.3% vs. 7.14%) with similar wound infection rates (4.3% vs. 4.2%). Hospital stay was similar (5.65 ± 3.7 vs 6.58 ± 4.6 days).

Conclusions: IA in the laparoscopic right hemicolectomy is a surgical option that require a longer surgical time, but which provides a surgical specimen comparable to the extracorporeal anastomosis. IA is associated with lower perception of pain and analgesic requirements. IA is superior in terms of the earliest digestive functional recovery, with a lower morbidity. All these clinical advantages would lead to an earlier recovery.



S. Symeonidis, S. Mpitsianis, L.L. Loutzidou, K. Galanos-Demiris, M.G. Pramateutakis, E.. Kotidis, N. Antoniou, O.I. Ioannidis, I. Mantzoros, S. Aggelopoulos, K. Tsalis 4th Department of General Surgery, General Hospital “G. Papanikolaou”, THESSALONIKI, Greece

Laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. Bile duct injury (BDI) is a rare but very serious complication of the procedure, with a significant impact on quality of life and overall survival. The high frequency of BDI with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of BDI is misinterpretation of biliary anatomy. Intraoperative cholangiography (IOC) has been advised by many authors as the technique reduces the risk of BDI. However, the procedure has inherent limitations and is therefore reserved for select cases. Fluorescent cholangiography using indocyanine green(ICG) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. A comparative study was contacted by administering ICG intravenously or intrabiliary during the operation.

Forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups:

In Group A ICG was administered in a dose 2.5 mg in 2 mL solution intravenously 1 hour before surgery.

In Group B ICG was injected intrabiliary in a 0.025 mg/mL solution mixed with the patient’s bile.

Also, we observed and analysed the following parameters, liver function, B.M.I, ASA score and possible complications, before and after operation.

Results: Group A. Intravenous ICG was administered in 20 patients. There was no any reaction and the extrahepatic biliary anatomy was identified well. There was no BDI or any complication related to the procedure.

Group B. ICG was injected intrabiliary in 20 patients during the laparoscopic procedure. In all but one patient the extrahepatic biliary tree was delineated very well. In one patient part of ICG solution was injected into the gallbladder wall and this resulted in a partially confusing image. There was no BDI and no postoperative complication

Conclusions: Fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation orintravenous injection 1 h before the procedure. The later technique is more easy to perform and does not require catheterization of the biliary tree.



P. Mascagni 1, C. Fiorillo1, T. Urade2, T. Emre3, T. Yu3, T. Wakabayashi4, E. Felli5, S. Perretta6, L. Swanstrom2, D. Mutter5, J. Marescaux4, P. Pessaux5, G. Costamagna1, N. Padoy3, B. Dallemagne4 1Endoscopia Digestiva Chirurgica, Policlinico Universitario “A. Gemelli”, ROME, Italy; 2IHU, STRASBOURG, France; 3Camma Group, ICube, University of Strasbourg, CNRS, IHU Strasbourg, STRASBOURG, France; 4IRCAD, STRASBOURG, France; 5Digestive and Endocrine Surgery, Nouvel Hopital Civil, University of Strasbourg, STRASBOURG, France; 6Digestive and Endocrine Surgery, IHU-Strasbourg, STRASBOURG, France

Aim: Surgical societies are united in promoting the Critical View of Safety(CVS) during laparoscopic cholecystectomy(LC). Nonetheless, reports have shown a discrepancy between the operative reports and the correct application of CVS, which may explain the stability of bile duct injury rates. Therefore, surgeons and computer scientists at our institution are developing a machine-learning algorithm to automatize CVS assessment. However, the lack of a consistent CVS video assessment framework limits the ability to generate data to train the artificial intelligence. Here we describe and test a method for CVS evaluation in videos.

Method: Between March and July 2016, 100 consecutive videos of LC performed at Nouvel Hospital Civil(Strasbourg, France) were recorded. Two independent reviewers assessed the achievement of CVS in the 60 s video sequences preceding clipping of cystic duct and artery. In addition to the ‘Doublet View’ method, a ‘Binary’ video evaluation method was tested: each of the 3 criteria composing the CVS(2 structures entering the gallbladder, clearance of the hepatocystic triangle and lower part of the cystic plate) was classified as achieved or not. If the 3 criteria were met, then the CVS was considered achieved. Inter-rater agreement for CVS and for each of the 3 criteria was evaluated.

Results: Twenty-two videos(12 fundus first and 5 partial LC, and 5 broken videos) were excluded from the CVS analysis. CVS elements were assessable in all but one 60 s videos sequences(98.72%). After mediation, CVS was achieved in 32/78(41.03%) of LC. The cystic plate was identified in only 52.56% of videos. Inter-rater agreement using the Doublet View vs. the Binary method was as follows: 83.33%(? = 0.54) vs. 88.46%(? = 0.75) for CVS achievement, 66.66%(? = 0.48) vs. 93.59%(? = 0.79) for the 2 structures, 65.38%(? = 0.45) vs. 82.05%(? = 0.62) for the hepatocystic triangle and 61.53%(? = 0.36) vs. 88.46%(? = 0.77) for the cystic plate (Fig. 1).

Conclusions: Reliable CVS assessment is crucial to generate consistent data for machine-learning algorithms aiming at decreasing bile duct injury after cholecystectomy. Our binary CVS video assessment method showed higher inter-rater reliability than the Doublet View, originally described for assessment of photos. Further studies are on going to validate the CVS assessment in videos and support our initial results.



M. Gholinejad, A.J. Loeve, J. Dankelman Department of Biomechanical Engineering, Delft University of Technology, DELFT, The Netherlands

The vital role of surgeries in healthcare requires a constant attention for improvement. Surgical process modeling is an innovative and rather recently introduced approach for tackling the issues in nowadays complex surgeries, involving complex logistics, much technology, and large teams. Surgical process modeling allows for evaluating the introduction of new technologies and tools prior to the actual development and is beneficial in optimization of the treatment planning and treatment performance in operating room. In this study, we first discuss the concepts associated with surgical process modeling, aiming to clarify them and to promote their use in future studies. Next, we apply these concepts to analyze the procedure of challenging interventions, minimally invasive liver treatment (MILT) methods, with the ultimate goal of improving and optimizing the treatment procedure. The procedure model of current treatment activities and planning of various MILT methods and the associated techniques, are analyzed and combined into a generic procedure model of MILT, which provides a firm foundation for qualitative and quantitative analysis of different MILT procedures. The generic procedure model is validated by data from Erasmus Medical Center (Rotterdam, The Netherlands) and Oslo University Hospital (Oslo, Norway). The proposed procedure model is designed to be a basis for improvement of the procedure and to determine how and where the new technologies can be best, effectively and efficiently, employed in the clinical practices prior to and/or during actual development of the new technologies for MILT. As a conclusion, the current work illuminates the importance of surgical process modeling for improving different aspects of treatment procedures and provides an overview of various modeling strategies that can be used to establish surgical process models. The generic procedure model of various MILT methods, including laparoscopic liver resection, laparoscopic liver ablation and percutaneous ablation, is introduced and validated which is a basis for introduction of the optimized procedure model of MILT methods in the clinical practice.&#13Funding: This work is part of the HiPerNav project that received funding from the European Union’s Horizon 2020 Research and Innovation program under grant agreement No 722068.



B.R. Lee, Y.R. Choi General surgery, Department of Surgery, Seoul National University Bundang Hospital, GYEONGGI-DO, Korea

Objective: To determine the most appropriate time to start total laparoscopic living donor right hepatectomy (TLDRH) based on the experience with laparoscopic liver resection (LLR).

Summary Background Data Accumulation of experience in LLR is essential before starting TLDRH to ensure donor safety.

Methods: We retrospectively reviewed data of 567 and 78 consecutive patients who underwent LLR and donor hepatectomy, respectively, between 2003 and 2017. Operative outcomes of laparoscopic major hepatectomy (LMH) were compared between two periods based on TLDRH introduction (Phase I 2003–2009 vs Phase II 2010–2017). Learning curve of LLR was evaluated using the cumulative sum (CUSUM) method to determine the optimal time of TLDRH introduction.

Results: A total of 132 LMHs (Phase I: 38 cases, Phase II: 94 cases) and 38 TLDRHs were performed. In LMH cases, hospital stay (12.63 ± 6.75:9.61 ± 8.20 days, P = 0.009) was significantly shortened, and EBL (1122.89 ± 1460.20: 931.88 ± 1855.85 ml, P = 0.024) was significantly decreased in Phase II. Although TLDRH was introduced after performing 38 LMHs, LMH learning curve was achieved after 73 cases in CUSUM analysis. However, when 73 LMH cases were performed, 15 TLDRH cases were already performed in our center. When comparing the operative outcomes before and after 15 TLDRH cases, operative time (min, 578.1 ± 110.65 vs. 422.3 ± 230.6, P = 0.024), hospital stay (days, 10.46 ± 3.45 vs. 9.09 ± 4.63, P = 0.23), and EBL (ml, 769.23 ± 523.02 vs 423.23 ± 323.38, P = 0.026) were significantly different.

Conclusion: Accumulating an experience of at least 73 LMH cases is needed in low-volume LT centers before starting TLDRH to ensure donor safety.



A.L. Moekotte 1, S. Lof1, S.A. White2, R. Marudanayagam3, B. al-Sarireh4, Z. Rahman5, Z. Soonawalla6, M. Deakin7, S. Aroori8, B. Ammori9, D. Gomez10, G. Marangoni11, M. Abu Hilal1 1HPB Surgery, University Hospital Southampton NHS Foundation Trust, SOUTHAMPTON, United Kingdom; 2HPB Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, NEWCASTLE, United Kingdom; 3HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, BIRMINGHAM, United Kingdom; 4HPB Surgery, Morriston Hospital, SWANSEA, United Kingdom; 5HPB Surgery, Royal Free London NHS Foundation Trust, LONDON, United Kingdom; 6HPB Surgery, Oxford University Hospitals NHS Foundation Trust, OXFORD, United Kingdom; 7HPB Surgery, Royal Stoke University Hospital, STOKE, United Kingdom; 8HPB Surgery, Plymouth Hospitals NHS Trust, PLYMOUTH, United Kingdom; 9HPB Surgery, Manchester University NHS Foundation Trust, MANCHESTER, United Kingdom; 10HPB Surgery, Nottingham University Hospitals NHS Trust, NOTTINGHAM, United Kingdom; 11HPB Surgery, University Hospitals Coventry and Warwickshire NHS Trust, COVENTRY, United Kingdom

Aims: The laparoscopic approach in distal pancreatectomy is associated with higher rates of splenic preservation compared to open surgery. Although favorable postoperative short-term outcomes have been reported in open spleen-preserving distal pancreatectomy when compared to distal pancreatectomy with splenectomy, it is unclear whether this observation applies to the laparoscopic approach. The aim of this study is to compare laparoscopic spleen preserving distal pancreatectomy (LSPDP) with laparoscopic distal pancreatectomy with splenectomy (LDPS), using propensity score matching.

Methods: This is a UK wide, propensity score matched study, including patients who underwent LSPDP or LDPS between 2006 and 2016. Short-term outcomes were compared between LSPDP and LDPS according to intention to treat. Additionally, risk factors for unplanned splenectomy were explored.

Results: A total of 456 patients were included from eleven centers (229 LSPDP and 227 LDPS). The mean age of the cohort was 56 ± 16 years old and 293 (64%) were female. The most common histopathologic diagnoses were neuroendocrine tumor (NET), Mucinous Cystic Neoplasm (MCN) and Intraductal Papillary Mucinous Neoplasm (IPMN). Splenic preservation was achieved in 184 (80%) of the attempted LSPDP. We were able to match 173 LSPDP cases to 173 LDPS cases. After matching, the groups were well balanced in terms of tumor size, age and sex. No differences were seen in postoperative morbidity between the groups. The only identified risk factor for unplanned splenectomy was tumor size = 30 mm.

Conclusions: A high splenic preservation rate was achieved with tumor size as a risk factor for unplanned splenectomy. Preserving the spleen during laparoscopic distal pancreatectomy is not associated with a lower postoperative morbidity compared to sacrifising the spleen. However, taking in consideration the long-term risks of post-splenectomy patients, the authors believe splenic preservation should be attempted in laparoscopic distal pancreatectomy for benign or low-grade malignant lesions as this study shows the approach is safe and feasible.


O008—ROBOTICS & NEW TECHNIQUES—Basic and Technical Research


A. Studier-Fischer 1, K.F. Kowalewski1, F.M. Schwab1, C. Haney1, I. Gockel2, B.P. Müller-Stich1, F. Nickel1 1Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, HEIDELBERG, Germany; 2Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, LEIPZIG, Germany

Aims: The intraoperative real-time evaluation of small intestinal perfusion is essential for proper resection, but also for sparing of healthy tissue and for anastomotic integrity. The aim of this study was the visualisation of small intestinal ischemia with Hyperspectral Imaging (HSI) and the comparison to conventional indocyanin green-based (ICG) evaluation in terms of sensitivity.

Methods: The HSI camera records a 3 dimensional data cube from a 2 dimensional surgical situs obtaining wavelengths between 500 and 1000 nm. The absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. A software calculates 4 different indices in real-time including an oxygen-based window. Artificial small intestinal ischemia was induced by a mesotomy of 15 cm in a porcine model. The intestinal site was recorded prior to and 2 min after ICG application (5 mg) with the HSI camera and the conventional ICG camera for comparison. ICG emits wavelengths of 810 nm that enhance the signal in the oxygen-based window of HSI.

Results: In preliminary results (n = 10) with 3 levels of criticality of which visual evaluation formed the middle perfusion margin (visually evaluated perfusion margin: VEPM) the conventional ICG was the least critical modality showing ICG signal 1.9 cm 95% CI [1.6 cm, 2.2 cm] away from VEPM towards mesotomic parts. HSI prior to ICG application was similar to VEPM. During augmented HSI (HSI after ICG application), sufficiently perfused parts became enhanced, demasking margin areas next to the mesotomy that would potentially lead to later necrosis and anastomotic insufficiency (HSI without ICG: 55.4% 95% CI [51.1%, 59.7%], HSI with ICG: 79.2% 95% CI [75.1%, 83.3%] (p < 0.001). Augmented HSI depicted a perfusion margin with a distance of − 2.2 cm 95% CI [− 1.8 cm, − 2.6 cm] away from VEPM.

Conclusion: HSI is a promising method for intraoperative identification of small intestinal ischemia. Conventional ICG is inclined to an overestimation of perfusion, but new approaches such as time-to-peak analyses are promising. When HSI is combined with ICG, sufficiently perfused intestinal areas are further enhanced, demasking critical margins that could otherwise lead to necrosis or anastomotic insufficiency. These preliminary findings need further validation.

O009—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


Y. Ushimaru 1, S. Katsuyama1, A. Oigawa2, K. Tanaka3, Y. Miyazaki3, T. Makino3, T. Takahashi3, Y. Kurokawa3, M. Yamasaki3, M. Mori3, Y. Doki3, K. Nakajima3 1Department of Next Generation Endoscopic Intervention, Osaka University, Suita, OSAKA, Japan; 2R&D center, Cardinal Health, FUKUROI CITY, Japan; 3Department of Gastroenterological Surgery, Osaka University, Suita, OSAKA, Japan

Background: Although ureteral catheters and ureteral fluorescence methods have been examined for the purpose of avoiding ureteral injury, they have not yet been standardized from the viewpoint of the complexity of the procedure and safety to living bodies. We jointly developed a near-infrared (NIR) fluorescent ureteral catheter made of fluorescent resin for non-invasive detection of the ureters. The aims of this study were (1) to evaluate its bench-top performance, and (2) to assert its safety and potential usefulness in a series of animal models.

Methods: [Bench-top study] We verified whether the NIR fluorescent catheter was actually stimulated by NIR with the use of a commercially available laparoscopic fluorescence imaging system. In addition, the influence of the imaging distance and the shielding object, such as 1.5 mm sliced pig loin with multiple sheets, was evaluated. [Performance study] The fluorescent ureter catheter with fixed specification was then evaluated on 5 pigs, to validate its safety and potential usefulness. Non-fluorescent, fluorescent ureteral catheters were placed alternatively in the left and right ureters. Image J software was used to quantify fluorescence signals and signal-to-background ratio (SBR) for the intraoperative images.

Results: [Bench-top study] A fluorescent ureteral catheter was successfully identified at all distances. The fluorescent catheter decreased in fluorescence in inverse proportion to the distance, and the fluorescence decreased in inverse proportion to the thickness of the intervening shield (two-way ANOVA, p < 0.01). In situations where shields were present, catheter positions could not be recognized with non-fluorescent catheters, but the fluorescent catheters could be still recognized.[Performance study] It was confirmed that the fluorescent catheter fluoresces at all distances (p < 0.01). There was no individual difference (p = 0.21), there was no left / right difference in the ureter (p = 0.79). The fluorescence of the fluorescent catheter decreased in inverse proportion to the distance (p < 0.01).

Conclusion: This new fluorescent ureter catheter showed promising performance in providing ureteral identification with high specificity during laparoscopic surgery. Real time, sensitive visualization, and absence of invasive ureteral instrumentation inherent to this technique may reduce complications related to variety of pelvic surgery.

O010—Robotics & New TECHNIQUES—Basic and Technical research


A.S.H.M. van Dalen 1, J. Jung2, E.J.M. Nieveen van Dijkum3, C.J. Buskens1, W.A. Bemelman1, T.P. Grantcharov2, M.P. Schijven1 1Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, AMSTERDAM, The Netherlands; 2Department of Surgery, International Centre for Surgical Safety, St Michael’s Hospital, University of T, TORONTO, Canada; 3Department of Surgery, Amsterdam UMC, University of Amsterdam, AMSTERDAM, The Netherlands

Introduction: The number of surgical adverse events is still too high. An important number of these adverse events occur within the operating room (OR) and are in fact preventable. In order to reduce adverse events in the OR, we simply need to know what went well and what can be done better. The aim of this study was to analyze and debrief a predefined selection of surgical procedures, with the use of an operating room ‘Black Box’, to identify commonly observed safety threats and resilience support events.

Methods: In the period 2017–2018, 35 predefined gastro-intestinal laparoscopic cases were recorded by the OR Black Box’. The postoperative Surgical Team Assessment Record (STAR) questionnaire was used. The recordings were analyzed by specifically trained raters, using the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety to identify relevant safety threat and resilience support events. Qualitative data analysis was used to identify the most commonly discussed events during the team debriefings.

Results: In only 26.5% (n = 65) of times OR team members, when asked direct following surgery, indicated that they had noticed aberrations (N = 234) during the case. A mean number of 52.5 (SD 15.0) relevant positive and negative events (e.i. aberrations) per surgical procedure were identified using the Black Box performance report. On average, 11.5 (SD 4.2) of events identified by the Black Box were rated as safety threats. Most events discussed during the team debriefings were related to communication.

Conclusion: These results once again highlighting the importance of clear and closed-loop communication in the operating room. Theatre staff underestimated the number of aberrations occurring in the OR, when asked to retrieve from memory. Postoperative structured team debriefing may be important for resolving incorrect assumptions between operating team members to avoid future unnecessary miscommunication.

O011—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


M. Wagner 1, A. Bihlmaier2, H.G. Kenngott1, P. Mietkowski1, S. Bodenstedt3, N. Nickel1, S. Speidel3, H. Woern2, T. Kroeger2, B.P. Müller-Stich1 1General, Visceral and Transplant Surgery, Heidelberg University Hospital, HEIDELBERG, Germany; 2Institute for Anthropomatics and Robotics, Karlsruhe Institute of Technology, KARLSRUHE, Germany; 3Translational Surgical Oncology, National Center for Tumour Diseases, DRESDEN, Germany

Aims: stablished surgical robots for laparoscopy, such as the DaVinci® or the Senhance™, are telemanipulators without any autonomous activities. Autonomous robots have been developed for laparoscopic camera guidance, but they follow simple rules such as keeping the instruments in the middle of the view. They do not adapt their behavior to different tasks, procedures or surgeons. We developed a robot for cognitive camera control that learns from experience, improves over time and adapts to the surgeons needs.

Methods: To enable robotic learning, a cognitive model was realized: the robot perceives its environment, interprets it according to a knowledge base and performs a context-aware action. By adding experience from robotic surgeries to the knowledge base the robot learns. For validation we used a phantom model of laparoscopic rectal resection. Here, n = 20 operations were performed with human camera guidance. To gain experience from these operations, laparoscopic video as well as trajectories of laparoscopic instruments were recorded. Each video frame was rated for good, neutral and poor camera guidance quality. Afterwards, machine learning (random forest algorithm) was used to train the robot in three consecutive steps. First, we performed surgery with two different robots, Viky® by Trumpf (Viky) and Light Weight Robot 4 by KUKA (LWR), based on the experience from human camera guidance (trials: Viky n = 5, LWR1 n = 5). Then, data from Viky was used to train LWR for another trial (LWR2, n = 5) and finally data from the trials LWR1 and LWR2 was used to train for LWR3 (n = 1).

Results: With increasing experience the duration of surgery decreased from 1704 s ± 244 s for LWR1 to 1406 s ± 112 s for LWR2 and 1197 s for LWR3. Rating of camera guidance (good/neutral/poor) improved with 38.6/53.4/7.9% for LWR1, 49.4/46.3/4.1% for LWR2 and 56.2/41.0/2.8% for LWR3.

Conclusions: We developed a robot for cognitive camera control that learned from experience and improved its performance over time. The underlying cognitive model lays the foundation for a new generation of cognitive surgical robots that provide the right assistance at the right time and adapt to a surgeons needs just as a good human assistant.



N.J. Curtis 1, G. Dennison2, J.A. Conti3, G.B. Hanna1, N.K. Francis2 1Surgery and Cancer, Imperial College London, LONDON, United Kingdom; 2General Surgery, Yeovil District Hospital, YEOVIL, United Kingdom; 3Colorectal Surgery, Portsmouth Hospitals NHS Trust, PORTSMOUTH, United Arab Emirates

Background: The EAES has recently published an intraoperative adverse event classification to assist the direct measurement and routine reporting of minimal access surgery interventions. We aimed to explore the clinically validity and reliability of the classification.

Methods: A prospective evaluation utilising case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision surgery randomised controlled trial was performed (ISRCTN59485808). Enacted adverse events identified with the observational clinical human reliability analysis technique were graded with the EAES classification by two blinded, independent assessors. Test-retest reliability was explored using grades previously applied during the development of the classification with intraclass correlation co-efficients calculated. Clinical validity was assessed using 30-day morbidity events, the Clavien–Dindo classification and the highest EAES grade per case.

Results: 77 laparoscopic cases (419 h of surgery) contained 1393 error events which were all successfully categorised. Excellent inter-rater and test-retest reliability was seen (ICC 0.957, 95% CI 0.952–0.961, p < 0.001 and ICC 0.893, 95% CI 0.88–0.904, p < 0.001 respectively. 61% of patients experienced post-operative morbidity (median 1 event, range 0–5). Labelling analysed cases by their highest EAES classification grade gave 53% grade 2, 43% grade 3 and 4% grade 4 procedures. 51% of grade 2 cases developed a morbidity event, but this significantly increased in grade 3 and 4 operations (70% and 100%, p = 0.043). The number of complications and highest recorded Clavien–Dindo grade increased with each additional grade (1.05 ± 1.3 vs. 1.48 ± 1.3 vs. 2.33 ± 0.6, p = 0.145 and median 1 vs. 2 vs. 3, p = 0.023 respectively). Anastomotic leak and re-operation were correctly captured by the allocated EAES grade (2.5% vs. 3.3% vs. 100%, p < 0.001 and 5% vs. 0% vs. 66%, p < 0.001 respectively). There was a significant rise in length of stay observed with increasing EAES grade (median 6 vs. 7 vs. 61 days, p < 0.001).

Conclusion: In the context of major laparoscopic surgery, the EAES intraoperative adverse classification is seen to be a clinically valid and reliable assessment method.



S.A. Lui 1, S. Wijerathne1, H. Khoe1, J.W. Low1, J. Ho2, D. Lomanto1, R. Ho3 1Surgery, NUHS, SINGAPORE, Singapore; 2Vascular Surgery, NUHS, SINGAPORE, Singapore; 3Psychological Medicine, NUHS, SINGAPORE, Singapore

Aims: Neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. The variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop is not properly studied before and we planned to do this using functional near infrared spectroscopy (fNIRS) which is a non-invasive optical brain imaging tool that measures cortical oxygenation change which is used as a marker of pre-frontal cortex activity (PFCA).

Methods: This randomised controlled trial examined the PFC activity differences in two groups of novice medical students during the acquisition of 4 basic laparoscopic tasks. ‘Trained-group’ had standerdised one-to-one training on the tasks, while the ‘Untrained-group’ had no prior trainining and was just shown a video of the tasks. The PFCA was measured pre and post intervention using a portable fNIRS device. Primary outcome was the difference in the PFCA pre and post intervention. Secondary outcomes were the differences in PFCA between the 4 tasks and between the sexes.

Results: 16 trained and 16 untrained medical students with an equal sex distribution and a comparable age distribution were invovlved in the study. All students were right handed. Trained group had a significantly attenuated PFCA in the ‘Precision-cutting’ (p = 0.011) and ‘Suture-insertion’ (p = 0.025) tasks compared to the untrained group. Subgroup analysis based on sex revealed significant attenuation in PFCA in trained females compared to untrained females across 3 of the 4 laparoscopic tasks: ‘Pegs-transfer’ (p = 0.013), ‘Precision-cutting’ (p = 0.034), ‘Suture-insertion’ (p = 0.03). No significant PFCA attenuation was found in male students who underwent training compared to untrained males.

Conclusion: A standardised laparoscopic training workshop promoted greater PFCA attenuation in female medical students compared to males. This suggests that female and male students respond differently to the same instructional approach. These results may have implications for surgical training and education such as a greater focus on one to one surgical training for female students and use of PFCA attenuation as a form of neurobiological feedback as a measure of learning curve in surgical training.



E. Leijte 1, I. de Blaauw2, C. Rosman1, S.M.B.I. Botden2 1Surgery, RadboudUMC, NIJMEGEN, The Netherlands; 2Pediatric surgery, RadboudUMC, NIJMEGEN, The Netherlands

Aims: Compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills as minimally invasive suturing. This study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted advanced suturing

Method: Novice participants, with the knowledge of basic surgical procedures, were recruited and performed three suturing tasks on the EoSim laparoscopic augmented reality simulator or the RobotiX robot assisted virtual reality simulator. Each participant performed an intracorporeal suturing, tilted plane needle transfer and anastomosis needle transfer task. To complete the learning curve, all tasks were repeated for maximal twenty repetitions or until a plateau was reached three consecutive times. Clinical relevant and comparable parameters regarding time (seconds), movements and safety were recorded. Intracorporeal suturing was used to visualize and compare the learning curves between the groups.

Results: Forty-six participants completed the learning curve, of which 16 laparoscopically and 30 robot assisted. When comparing the suture time, the plateau was reached much faster in the robot assisted group (7–9 repetitions) than the laparoscopic group (10–12 repetitions) as shown in Figure 1. There was a significant difference in ‘time per suture’, during the whole learning curve with median values of 637 versus 251 (first knot), 450 versus 147 (fifth) and 186 and 115 (eighteenth), all with a p < 0.05. However, the parameter ‘adequate surgical knot’ was reached earlier in the laparoscopic group than in the robot assisted group. First: 69% versus 60%, fifth: 100% versus 70%, and eighteenth: 100% versus 83%. When assessing the ‘needle out of view’ parameter, the robot assisted group scored a median of 0.3 and 0.0 s during the first, respectively eighteenth knot, and the laparoscopic participants had their instruments out of view for 41 and 17 s during the first respectively eighteenth knot.

Conclusion: The learning curve of minimally invasive suturing can be reduced with the use of robot assisted surgery, with a specific reduction in operation time. The rate of adequate knots seemed to remain lower in robot assisted surgery, although this could be due to the virtual reality aspect of the simulator.




M. Pizzicannella 1, C. Fiorillo1, P. Mascagni1, M. Vix2, D. Kadoche2, D. Mutter2, J. Marescaux3, S. Perretta1 1IHU, STRASBOURG, France; 2Digestive and Endocrine Surgery, Nouvel Hopital Civil, University of Strasbourg, STRASBOURG, France; 3IRCAD, IRCAD Research Institute against Digestive Cancer, STRASBOURG, France

Introduction: Endoscopic sleeve gastroplasty (ESG) is a novel promising bariatric endoscopy treatment. Gastric volume reduction and delayed gastric emptying are the mechanisms driving weight loss. However, little is known about the factors influencing the effectiveness of weight loss overtime. The present study aims at evaluating the correlation between endoscopic suture appearance and excess weight loss (EWL%) at 6 and 12 months follow up.

Patients and methods: All patients who underwent follow-up endoscopy at 6 and 12 months after ESG were included. ESGs were classified in 3 groups according to endoscopic appearance of the gastric sutures: optimal (group 1) when all stitches were in place and tights; suboptimal (group 2) when one or more stiches were displaced; loose (group 3) when all the sutures were completely disrupted. BMI at enrollment and EWL% at 6 and 12 months were recorded and compared to the endoscopic appearance.

Results: A total of 53 patients were included in the analysis. At 6 months, 25 (47.2%) patients had an optimal ESG, 24 (45.3%) had a suboptimal sleeve and 4 (7.5%) had complete sutures failure.

BMI at enrollment and EWL% were respectively 37.7 ± 4.2 and 36.6 ± 21.3% for group 1, 43.6 ± 6.7 and 22.77 ± 18.7% for group 2 and 50.7 ± 14.4 and 7.8% ± 16.5% for group 3. Twenty five patients had 12 months EGDS: 5(20%) presented an intact ESG and were classified in group 1, 15 (60%) in group 2 and 5 (20%) in group 3. Twelve months EWL% was respectively 47.6 ± 9.1%, 31.3 ± 29.3 and 12 ± 14.4%. Initial BMI significantly correlated with suture status at both 6 (rho − 0.528; p < 0.001) and 12 months (rho − 0.423; p = 0.035) follow-up. Furthermore, the sutures’ appearance itself correlated with EWL% at both time points (rho +0.416; p = 0.002 and rho 0.439; p = 0.028 respectively).

Conclusion: Our preliminary results show that the aspect of the endoscopic suture has a significantly impact on EWL% at 6 and 12 months after ESG. Furthermore, BMI at enrollment seems to predict endoscopic suture duration overtime. Larger studies and longer follow-up are needed to further validate our preliminary findings.



I. Boskoski, V. Bove, R. Landi, P. Familiari, A. Tringali, V. Perri, G. Costamagna Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, ROME, Italy

Background and aim: Endoscopic sleeve gastroplasty(ESG) is a relatively novel endoscopic procedure that reduces the gastric lumen with proven less complications and less 6 months weight loss compared to laparoscopic sleeve gastroplasty (LSG). At present there are no studies investigating the role of multidisciplinary approach in ESG. The aims of the present study were to evaluate the role of multidisciplinary assessment(MA) prior ESG, weight loss outcomes, quality of live improvements and adverse events.

Material and methods: From May 2016 to May 2018 all patients that underwent ESG were retrospectively evaluated from a prospective database. Until September 2017 before ESG only psychiatric evaluation was requested, while after this date we adopted the guidelines of the Italian Society for Obesity Surgery and all patients were evaluated on a multidisciplinary fashion prior ESG. The multidisciplinary team was composed by:gastroenterologist, surgeon, psychiatrist, endocrinologist and dietitian. Patients were divided in two groups:group 1 were patients with ESG before MA and group 2 were patients with ESG after MA. We compared this two groups in terms of weight loss outcomes, quality of live improvements and adverse events. Quality of live was measured with the Bariatric Analysis and Reporting Outcome System(BAROS).All procedures were done with the Apollo Overstitch suturing system(Apollo Endosurgery) and a double channel gastroscope Olympus 2TGIF-160(Olympus Japan).All procedures were done in general anesthesia and with insufflation of CO2. All patients had ambulatory visit t 1, 3 and 6 months after ESG and weight loss outcomes were measured in terms of Excess Weight Loss (%EWL),the Total Body Weight Loss (%TBWL) and BAROS scale were assessed. Statistical analysis was done with chi-square test and < 0.05 value was considered significant.

Results: 31 patients were identified (20 female; mean age 45.4, range 23–73). Mean BMI at inclusion was 41.6(range 31.6–62.4). Mean %EWL and %TBWL at 6 months was 37.1 and 16.7 respectively(Table 1).Non procedure related complications were observed.

Comparing the two groups there was significant(P < 0.05) difference in terms of %EWL and %TBWL (Table 2),with better results in group 2. There was also a significant improvement in the BAROS scale in the patients in group 2.

Conclusions: MA before ESG has a fundamental role in terms of better procedure outcomes for both weight loss and quality of live in obese patients.



I. Mizrahi1, R. Grinbaum1, R. Elazary1, T. Mordechay-Heyn 1, H. Jacob2, J. Epstein2, N. Beglaibter1 1Surgery, Hadassah Medical Center, JERUSALEM, ISRAEL, Israel; 2Gastroenterology, Hadassah Medical Center, JERUSALEM, ISRAEL, Israel

Aims: The over-the-scope clip (OVESCO) is a novel endoscopic tool that enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OVESCO for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG).

Methods: A prospectively maintained IRB-approved institutional database was queried for all patients treated with OVESCO for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OVESCO as defined by return to complete oral nutrition and no evidence of leak on imaging. Secondary outcome was the number of additional endoscopic or surgical procedures needed following OVESCO.

Results: Twenty-five patients (12 males, 13 females) were treated with OVESCO for staple line leaks following LSG. The median age was 35 years (range 18–62), and mean body mass index was 44 kg/m2. Nine patients (35%) were referred from an outside hospital. The median time from index operation to leak diagnosis and from leak diagnosis to OVESCO was 18 days (range 2–118), and 6 days (range 1–120), respectively. All patients had upper staple-line leaks near the gastroesophageal junction. Initial treatment included antibiotics—6 patients; computed tomography guided drainage and antibiotics—7 patients; and laparoscopic drainage—12 patients. OVESCO led to final resolution of leak in 8 patients (33%) within 70 days of clip deployment (range 41–136). Leaks which persisted following OVESCO were eventually resolved with a combination of OVESCO and stent—5 patients (21%), total gastrectomy and esophago-jejunostomy—10 patients (42%), and endoscopic suturing—1 patient (4%). One mortality was noted in a patient who suffered multiorgan failure. The number of additional endoscopic sessions ranged from 1 to 10 (median 2). No procedure related complications were noted. All patients were treated with total parenteral nutrition and the total length of stay was 49 days (range 13–127).

Conclusions: Despite its low success rate, OVESCO should be part of the bariatric surgeon’s non-surgical armamentarium in treating staple line leaks following LSG.



R. Bademci 1, R. Vilallonga2, P. Alberti2, R. Renato2, C. Yuhamy2, S.S. Cordero2, L. Posadas2 1General surgery, Istanbul medipol üniversitesi, ISTANBUL, Turkey; 2Bariatric surgery, Vall d’hebron, BARCELONA, Spain

Background: In cases of morbid obesity, treatment is generally applied as either a surgical or endoscopic approach. The number of Primary Obesity Surgery Endolumenal (POSE) procedures is increasing but the reliability and effectiveness is unclear as yet. The aim of this study was to present a series of cases that required revision surgery due to POSE failure and to reveal possible alternative surgeries.

Materials and methods: A retrospective comparison was made of the data of obese patients with POSE failure and conversion to surgical procedures between 2016 and 2018 in respect of operation, medical illness and BMI results.

Results: The patients comprised 60% females, 40% males with a mean age of 44.8 ± 12.4 years and mean follow-up period of 12.6 ± 8.3 months. On average, patients lost 24.1 ± 8.9 kg, with an average excess weight loss of 47.6%.

Conclusion: No firm conclusions can be drawn from such a small group. Although SG seems to be a safe procedure and should be considered as the first technique to be applied following POSE failure, it is possible to perform gastric bypass on patients with this endoscopic precursor.



S. Mafeld 1, R. Zener2, A. Okrainec3, E. Shlomovitz1 1Interventional Radiology / General Surgery, University Health Network, TORONTO, Canada; 2Interventional Radiology, University Health Network, TORONTO, Canada; 3General Surgery, University Health Network, TORONTO, Canada

Introduction: The population of post bariatric surgery patients is rapidly increasing worldwide. Due to the altered anatomy post Roux-en-Y gastric bypass (RYGB), conventional endoscopic management for choledocholithiasis is challenging. These patients are now commonly managed by means of a laparoscopic assisted ERCP. Although effective, this requires significant resource utilization and potential morbidity related to the need for surgical intervention. We present our preliminary experience with a purely percutaneous management of choledocholithiasis in bariatric patients post-RYGB.

Methods: A retrospective single center review identified five patients with choledocholithiasis after bariatric RYGB who underwent percutaneous CBD access and treatment by interventional radiology. Four patients underwent percutaneous transhepatic CBD access while one patient underwent percutaneous trans-cholecystic CBD access. In three of the five patients conscious sedation alone was sufficient to perform the procedure.

Results: All patients had radiologically confirmed choledocholithiasis and were clinically symptomatic prior to intervention. The biliary tree was successfully accessed percutaneously and cleared in all five patients. In the four patients where a percutaneous transhepatic access was utilized, three patients required only fluoroscopic balloon sphincterplasty and sweep of the CBD to clear the ductal stones, while the fourth required percutaneous cholangioscopy assisted lithotripsy for clearance. In the fifth patient with non-dilated intrahepatic bile ducts a trans-cholecystistic approach into the CBD was utilized with percutaneous cholangioscopic assistance to clear the ductal stones. All procedures were completed successfully with no post procedure complications.

Conclusion: Percutaneous clearance of CBD stones in bariatric patients presents a minimally invasive alternative to current surgical practice. The use of conscious sedation and the purely percutaneous approach may potentially reduce morbidity and resource utilization for this increasingly common clinical scenario.



D. Godoroja 1, A. Ene1, R. Badescu1, G. Constantin2, A. Fodor1 1Anaesthesia and Intensive Care, Ponderas Academic Hospital, BUCHAREST, Romania; 2Anaesthetist Ponderas Academic Hospital, BUCHAREST, Romania

Background and Aim: In morbidly obese patients, anaesthesiologists are recommended to use an obstructive sleep apnoea safe anaesthetic technique, minimising opioids. The primary goal of the study was to assess the efficacy of using a low opioid protocol for general anaesthesia in bariatric surgery.

Method: A protocol of low opioid general anaesthesia for obese patients undergoing laparoscopic bariatric operations has been introduced in our Center in 2016. The protocol was used by all anaesthetists and was based on using low dose of Fentanyl, adjuvants, and opioid free analgesics (Table 1). No intravenous morphine was administered at the end of the procedure. All patients received a protocolised opioid free multimodal postoperative analgesia and intravenous morphine only if the visual analogue score (VAS) was higher than 5. Cumulative opioid (iv mg morphine) consumption for 24 h and pain severity scores at rest and movement were recorded at 1, 4, 12, and 24 h postoperatively.

Results: Between February 2016 and August 2017 in Ponderas Academic Hospital, 1227 patients were operated on for bariatric procedures. The descriptive statistical data showed that 70.18% were women and 29.82% men with a mean age of 40.63 (± 12.03 SD) and the median BMI(kg m−2) of 39.7 (IQR-9.30). 247(20.13%) patients presented severe obstructive sleep apnoea and received CPAP treatment. Out of 1227 patients only 361 (29.43%) received intravenous morphine in the first 24 h after operation at a VAS higher than 5. The median of cumulative consumption of morphine at 24 h in the morphine group was 6.00 (IQR 2.00). The pain scores at rest and with movement during all measured intervals were significantly low.

Women were more susceptible to the pain with increased consumption of morphine. In the CPAP group of patients the morphine used was statistic significantly lower (p < 0.00001). Only 14% of the patients with severe OSA needed morphine comparing with 33% of the patients without OSA.

Conclusion: The low opioid anesthesia protocol in bariatric patients proved to be efficient and its use should be extended in obese patients undergoing minimal invasive surgery.



A. Jarrar 1, N. Eipe2, A. Budiansky2, C. Walsh1, J. Mamazza1 1General Surgery, The Ottawa Hospital, OTTAWA, Canada; 2Anesthesia, The Ottawa Hospital, OTTAWA, Canada

Aim: The aim of this study is to evaluate the efficacy of a laparoscopically-guided, surgeon- performed transversus abdominis plane (TAP) and rectus sheath (RS) block in reducing pain while improving functional outcomes in patients undergoing bariatric surgery. there are limited evidence-based recommendations and no ideal analgesic regimen exists for patients with Morbid Obesity.

Methods: 150 patients elective laparoscopic Roux-En-Y gastric bypass (LRYGB) have been recruited to this double-blinded, placebo-controlled Randomized Control Trial from a provincial Bariatric Center of Excellence over a period of six months. Patients underwent objective prehabilitation with 6-min walk test (6MWT) and peak expiratory flow (PEF). Patients have been electronically randomized on a 1:1 basis to either an intervention or placebo group. At the end of the surgery, patients in the intervention arm receive a total of 60 mL 0.25% Ropivacaine, divided into four injections: two 20 mL each for TAP and two 10 mL each for RS block under laparoscopic visualization. The placebo arm receives normal saline in the same manner. All patients, providers and research personnel were blinded and standardized surgical and anesthetic protocols were followed, with careful adherence to established Enhanced Recovery after Bariatric Surgery (ERABS) protocols.

Results: baseline information for 150 patients is being collected and analyzed, Cumulative narcotic use was collected and all patients underwent PEF and 6MWT testing in addition to assessment of the quality of recovery using validated questionnaire (QOR-40), the data is being analyzed and we will present results through publication.

Conclusion: 30% reduction in narcotic use is a significant improvement in patient outcomes, this study adds to the body of evidence of best practices in enhancing recovery for bariatric patients.



C.E. Boru, M.G. Coluzzi, F. de Angelis, G. Silecchia Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Sapienza University of Rome, Dept. of Medico-Surgical Sciences & Biotechnologies, LATINA, Italy

Hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy (LSG) has been advocated to reduce the incidence of postoperative gastroesophageal reflux disease (GERD) and/or intrathoracic migration (ITM). The necessity of intraoperative repair in asymptomatic patients is still controversial. Previous, mid-term results of a prospective, comparative study evaluating posterior cruroplasty concomitant with LSG (group A 48 patients with simple vs. group B 48 patients with reinforced with bioabsorbable mesh) confirmed the safety and effectiveness of simultaneous procedures. Present aim was to report the 60 months follow-up update, evaluating GERD and esophageal lesions’ incidence and HH’s recurrence.

Results: Follow-up of was completed in 79.5% of the patients.Recurrent GERD in 6/32 (18.8%, group A) and in 9/44 (20.5%, group B) was registered (p > 0.05).Grade A esophagitis and GERD was shown in 2 patients (6.25%), respectively 2 (4.5%) of each groups (p > 0.05), and recurrent HH was confirmed later by contrast study and CT scan. Neither Barrett’s lesions nor de novo GERD were found. A total of 12 patients (12.5%, 8 respective 4) were converted within five years for persistent/recurrent GERD, with only 1 case of de novo (group B, shown in the initial 21 months follow-up). Failure of the initial cruroplasty with ITM was recorded in 4 patients (13% for group A and 7.4% for group B); hence, a repeat posterior, reinforced cruroplasty with bioabsorbable mesh was performed.

Conclusions: Accurate patient selection (absence of large HH, absence of severe esophagitis, absence of severe long-lasting symptoms), proper sleeve technique (absence of tight sleeve), combined with posterior cruroplasty (simple or reinforced, based on hiatal defect’s dimensions and quality of the crura) ensures effectiveness, with a rate of failure (recurrence) at five years of 9.1%. Outcomes of LSG combined with posterior cruroplasty were satisfactory in all patients.



I.C. Hutopila, C. Copaescu General and Bariatric surgery, Ponderas Academic Hospital, BUCHAREST, Romania

Background: After the Laparoscopic Sleeve Gastrectomy (LSG) alone or associated with calibration of the esophageal hiatus, for some patients the reflux symptoms worsen postoperatively due to development of a hiatal hernia (HH) or due to the recurrence of the HH previously repaired. For these situations, when the conservative treatment fails, are proposed some surgical solutions, one of them Cardiopexy with Teres ligament—Narbona Arnau.

Objective: Is to establish a standardized laparoscopic technique for cardiopexy using the Teres ligament (Narbona Arnau technique) and to analyze the procedure’s outcomes.

Methods: The study was performed in a Bariatric and Metabolic Center of Excellence—Ponderas Academic Hospital. All the patients undergoing Narbona Arnau procedure to control GERD after LSG since 2014 were included and prospectively analyzed. The selection criteria included LSG patients, presenting HH and symptomatic GERD. Preoperative investigations were upper gastrointestinal endoscopy, radiological contrast study, pH—metry, computed tomography with oral contrast.

Results: 28 patients were included into the study. GERD and HH were preoperatively documented in all the cases. One patient was excluded after 2 years of follow up after being converted to a laparoscopic Roux-en-Y gastric bypass, for intense relux symptoms. No incidents during surgery. For 8 cases laparoscopic Narbona Arnau technique was performed concurrent with re-sleeve gastrectomy and gastric curvature plication. Without postoperative complications. Postoperative follow- up at 6 months, 1, 2 and 3 years, the percentage of patients without GERD symptoms and free of treatment with PPIs was 64,28%, 82,14%, 71,42%, respectively 66.66%. At 3 years postoperatively the upper GI endoscopy showed remission/ improvement of the degree of esophagitis for 17 patients. For the same period of follow-up, the Ph-metry highlighted a normal value of DeMeester score for 62.96% o patients (all the patients had preoperatively high De Meester scores). No objective signs of hiatal hernia recurrence at imagistic investigations and upper gastrointestinal endoscopy were encountered.

Conclusions: Complete preoperative evaluation is mandatory for choosing the optimal intervention. Laparoscopic Narbona Arnau technique after LSG is proved to be a good option for the treatment of symptomic GERD, but further studies with high-volume patients are necessary.



A. di Palma, A. Maeda, T. Jackson, A. Okrainec Surgery, University Health Network, TORONTO, Canada

Introduction: Marginal ulcer (MU) formation is a known complication following Roux-en-Y gastric bypass (RYGB) for weight loss. Although most respond to medical treatment, many patients have recurrent or chronic MU, with some requiring surgical revision. Although non-steroidal anti-inflammatory drug (NSAID) use, smoking and H. pyloriinfection have been proposed as risk factors for MU, little is known about what increases the likelihood of developing recalcitrant ulcers. The goal of this study was to identify potential risk factors for recurrent or chronic MU, including those requiring surgical revision.

Methods: All patients undergoing RYGB between 2011 and 2017 at an academic centre in Toronto, Ontario were included. Patients with a post-operative diagnosis of MU were identified from the institution’s bariatric database and had their medical records reviewed. Patient characteristics, operative data and surgical outcomes were collected for statistical analysis.

Results: A total of 2,830 RYGB were performed during the study period. The incidence of MU was 6.9% with 4.5% having a single episode, 1.4% developing recurrent but medically-responsive MU and 1% undergoing revisional surgery. Patients requiring revision were significantly younger than patients with a single episode of MU or recurrent medically-responsive MU (39.2 vs. 44.5 and 41.8 years, p = 0.027). This effect disappeared however when a multivariate logistic regression model was applied, identifying previous smoking history (OR 7.98, 95% CI 2.35–27.09) and therapeutic immunosuppression (OR 11.6, 95% CI 1.18–114.07) as the primary risk factors for MU requiring surgical revision. NSAID use, H. pyloriinfection and a history of peptic ulcer disease did not significantly predict chronic or recurrent MU requiring surgical treatment.

Conclusions: Patients with a history of smoking prior to RYGB and patients on immunosuppressive medications were at significantly higher risk of developing MU requiring surgical revision in comparison to patients that responded to medical treatment. Further studies are needed to validate these findings and determine how they can inform peri-operative management of the bariatric patient.



F. Pennestrì 1, F. Prioli1, P. Gallucci1, P. Giustacchini1, L. Ciccoritti1, L. Sessa1, P. Aceto2, R. Bellantone1, M. Raffaelli1 1U.O.C. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, ROME, Italy; 2U.O.C. Anestesia delle Chirurgie Generali e dei Trapianti, Fondazione Policlinico Universitario A. Gemelli IRCCS, ROME, Italy

Aims: Laparoscopic intracorporeal suturing and knot tying for anastomosis are considered the most difficult laparoscopic skill to master. The introduction of barbed sutures seems to facilitate the practice, with bariatric surgery being one of the specialties that can most benefit from them. The aim of this study was to establish the safety and efficacy of barbed suture to close the gastrojejunal anastomosis (GJA) and the jejuno-jejunal anastomosis (JJA) in bariatric laparoscopic procedure procedures (Roux-en-Y gastric bypass—RYLGB) using propensity score matching (PSM) analysis.

Methods: A retrospective analysis of patients who underwent primary bariatric procedures (RYLGB) between January 2012 and October 2018 was performed. PSM analysis was performed to overcome patient selection bias (age, gender, BMI, previously abdominal operations, comorbidities) between the two types of sutures (barbed sutures—BS, and conventional stutures—CS). The primary outcome measure were the operative time and the incidence of leak, bleeding and stenosis. The secondary outcomes were the post-operative hospital stay and the incidence of late complications (internal hernias and small bowel obstructions).

Results: A total of 969 patients were reviewed. After PSM, 322 (161 BS vs 161 CS) patients were apiece compared (chi-square 0.287, p = 0.862). Median operative time was significantly shorter [65(25) vs 95(45) min p < 0.001] for BS. Median Post-operative hospital stay was significantly shorter for BS [2(1) vs 5(1) days p < 0.001). Post-operative 30th-days complications were comparable: one case of GJA’s leakage for CS (p = 0.5) and one case of JJA’s stenosis for BS (p = 0.5). Median follow-up was significantly shorter for BS (p < 0.001). At mean follow up of 26.06 months the rates of small bowel obstructions were comparable (BS 2(1.2%) vs CS 1(0.6%), p = 0.562); instead the rates of internal hernias were significantly lower for BS (0(0%) vs 7(4.4%), p = 0.007).

Conclusions: Despite some of the results of the present study may be influenced by increasing surgical skill during the study period, barbed sutures appear to be effective in reducing the operative time, and as safe as conventional suture to close gastro-jejunal anastomosis and jejuno-jejunal anastomosis in bariatric surgery (RYLGB). Further studies are necessary to draw definitive conclusions.



M.J. García-Oria 1, J.A. Rivera1, M. Artés1, J. Alvarez1, B. Olivan2, A. Sánchez1, P. Pla1, C. León-Gámez1, A. Equisoain1, L. Román1, D. Gonzalez1, X. Rial1, X. Remirez1 1Cirugía General y del Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, MADRID, Spain; 2Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, MADRID, Spain

Aims: Laparoscopic One Anastomosis Gastric Bypass (OAGB) is an accepted bariatric technique, but few randomized prospective trials have compared it with Laparoscopic Roux-en-Y Gastric Bypass (LRYGB). We have conducted a study comparing these two techniques and herein we present the weight loss data in the first two years of follow-up.

Methods: Prospective Randomized Clinical Trial, (ClinicalTrials. gov Identifier: NCT02939664). One group of patients of the study was done a LRYGB, and the other group of patients was performed the OAGB. The investigators randomly assigned 10 patients to each group, n = 20. We used the non-parametric Mann-Whitney test for statistical analysis of quantitative parameters considering a significant p < 0.05. Patients with BMI between 40-50 kg/m2 were included in the study, and randomized in a 1:1 ratio to the LRYGB group or the OAGB group. Patients with gastroesophageal reflux disease were excluded from the study.

Results: The two groups are comparable in the preoperative parameters, and in terms of weight evolution we found a significantly different percentage of excess weight loss and percentage of excess body mass index loss (p < 0.05) at 3,6,9,12 and 18 months between the two groups, with greater weight loss in the OAGB group.

Conclusion: In the follow-up during the first year and a half the OAGB has better weight loss results than the BPGYL.



V.V. Grubnik 1, O.V. Medvedev2, V.V. Ilyashenko2, S.A. Usenok2, V.V. Grubnyk2 1Department of surgery, Odessa medical university, ODESSA, Ukraine; 2Department of surgery #1, Odessa medical university, ODESSA, Ukraine

The aim of this study was to compare the effectiveness of laparoscopic sleeve gastrectomy (LSG) with new surgical procedure: sleeve gastrectomy with single anastomosis sleeve ileal bypass (LSG + SASI) for the treatment of patients with diabetes mellitus type 2 (DM).

Methods: 48 obese patients with DM type 2 were divided in two groups: I group (25 patients) consisted from 15 women and 10 men age 36 to 64 years, mean body mass index (BMI) was 49.7 ± 8.6 kg/m2 . LSG was performed in all patients of the I group. II group (23 patients) consisted from 14 women and 9 men, age 39–69 years, mean BMY was 51.8 ± 7.4 kg/m2. LSG + SASI was performed in all patients of the II group. There were no statistically significant difference between two groups in demographic, BMI, and comorbidities. Excess weight loss percentage (%EWL), the total weight loss percentage (%TWL) and diabetes improvement were analyzed.

Results: There were no serious complications and mortality in the both groups. There were no symptoms of malabsorption in the patients of II group after LSG + SASI. After 24 months the patients of the II group lost more %TWL and %EWL and the difference was statistically significant (p < 0.05). %EWL in the I group was 69.7 ± 9.2%, in the patients of the II group—80.7 ± 13.4% (p < 0.05). Resolution of DM type 2 was in 14 (56%) patients from the I group and in 20 (87%) from the II group (p < 0.01).

Conclusion: Sleeve gastrectomy with with single anastomosis sleeve ileal bypass is more effective than LSG in the treatment of DM type 2 associated with obesity.



M. Wysocki1, P. Malczak1, M. Wierdak 1, M. Janik2, M. Waledziak2, P. Lech3, N. Dowigiallo-Wnukiewicz3, M. Orlowski4, H. Razak Hady5, M. Proczko-Stepaniak6, K. Major7, M. Pisarska1, J. Szeliga8, M. Pedziwiatr1, A. Budzynski1, P. Major1 12nd Department of General Surgery, Jagiellonian University Medical College, KRAKOW, Poland; 2Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, WARSAW, Poland; 3Department of General and Minimally Invasive Surgery, University of Warmia and Mazury, OLSZTYN, Poland; 4General and Vascular Surgery Department,, Ceynowa Hospital, CEYNOWA, Poland; 5Department of General and Endocrinological Surgery, Medical University of Bialystok, BIALYSTOK, Poland; 6Department of General, Endocrine and Transplant Surgery,, Medical University of Gdansk, GDANSK, Poland; 7Faculty of Health Sciences, Jagiellonian University Medical College, KRAKOW, Poland; 8Department of General, Gastroenterological, and Oncological Surgery, Nicolaus Copernicus University, TORUN, Poland

Aim: To determine if there are correlations between of C-reactive protein, procalcitonin and white blood count measured in first, second and third postoperative day after bariatric surgeries and postoperative morbidity (1-month and 12-months), length of hospital stay (LOS) and hospital readmissions.

Methods and Procedures: Retrospective cohort study of patients who underwent laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (GB) or mini-gastric bypass (MGB) for morbid obesity in seven referral bariatric centers. Patients were divided into two groups: complicated group—patients with postoperative complications (in 1 month or 12 months postoperative period) and non-complicated group—patients without postoperative morbidity. Primary endpoint: to determine utility of routinely tested inflammatory markers in prognosis of perioperative (30-days) and postoperative (12-months) morbidity rates. Secondary endpoints: utility of inflammatory markers to determine risk of LOS after bariatric surgeries and readmissions.

Results: 2125 patients, 68% females and 32% males in median age of 43 years were included. Postoperative morbidity was 7.29% patients, of who 112 cases occurred in first postoperative month and 43 cases after first postoperative month during 12-months follow-up. Sex, age, BMI and co-morbidities did not differ complicated and non-complicated cases. In complicated group LOS was significantly longer as well as readmission rate. CRP (OR 1.02, 95% CI: 1.01–1.03), WBC (1.23, 1.15–1.32), PCT (17.18, 3.09–95.46) on POD1 used as continuous variables were significantly increasing OR for perioperative morbidity. ROC analysis indicated suggested cut-off point of CRP on POD1 indicating for risk of perioperative morbidity for 23.8 mg/L, WBC for 10 × 103/mm3, and PCT for 0.22 ng/mL. In case of postoperative morbidity inflammatory parameters on POD1 were not significantly related to ORs. CRP (OR 1.02, 95% CI 1.01–1.03), WBC (1.10, 1.02–1.20), PCT (4.7, 1.12–19.64) were increasing OR for prolonged LOS. CRP (OR 1.01, 95% CI 1.00–1.03), WBC (1.21, 1.09–1.33) on POD1 were significantly increasing OR for readmissions. ROC analysis indicated suggested cut-off point of CRP on POD1 indicating for risk of readmissions for 94 mg/L, WBC for 14.5 × 103/mm3.

Conclusion: Even moderate increase in inflammatory parameters on POD1 should alert surgeon for possibility of increased chance for perioperative morbidity, prolonged LOS and hospital readmissions.



J. Falckenheiner 1, A. Camacho2, J.A. Prada3, G. Perez Arana3, J.M. Pacheco1, M. Mayo1 1General Surgery, Puerta Del Mar Hospital, Cadiz, Spain; 2General Surgery, Puerto Real Hospital, Cadiz, Spain; 3Anatomy And Embriology, Cadiz University, Cadiz, Spain

Aims: Study the physiological mechanisms dependent on the enteropancreatic axis that accompanies bariatric surgery in a healthy animal model.

Analyze the relationship between Glucagon like Peptide 1 (GLP-1) and Glucose dependent insulinotropic polypeptide (GIP) in the small bowel.

Compare the impact of intestinal GLP-1 on its receptors in beta cells of the pancreas.

Methods: Healthy Wistar male rats between 12 and 14 weeks of age were used. Five groups were randomly assigned. The control groups were divided into Fasting Control (F) and SHAM (Surgical Control). The surgical groups were separated into Vertical Gastrectomy (GS), 50% resection of the middle small bowel (RI50) and gastric bypass (GB). Three months later all the animals were sacrificed. The total number of positive GLP-1 and GIP cells in the duodenum, jejunum and ileum were studied. The total number of GLP-1 receptors (rGLP-1) expressed in pancreatic beta cells was also studied. The hormonal test was performed using immunohistochemical techniques, and were compared using the analysis of variance (ANOVA).

Results: An increase in the expression of GLP-1 was observed in the GB and RI50 in the duodenum and ileum. In the same way, a greater number of GLP-1 was identified in the GB group of the jejunum.

In the GIP study, there was a significant increase of this hormone in the duodenum of the GB and RI50 groups.

Regarding rGLP-1 in the pancreas, there is a statistically significant increase in the GB and RI50.

Conclusions: We can confirm the existence of GLP-1 cells throughout the intestinal frame outside of their confinement in the ileum. The significant increase of GLP-1 and GIP cells in the malabsorptive groups demonstrate the importance of the premature passage of nutrients to the distal bowel as support for the ‘Hindgut theory’. These results also offer us an indirect evidence of an intermediate and regulatory mechanism of hormonal homeostasis in the enteropancreatic axis.

Regarding the increase of pancreatic receptors in parallel with the intestinal expression of GLP-1 of a healthy rat, reinforces the idea of an active hormonal counter-regulator between the expression of GLP-1 and its physiological effects on the enteropancreatic axis .



A. Almunifi 1, S.D. Aldeghaither2, T. Debs3, I. Ben Amor3, J.G. Gugenhiem3, M. Ibrahim4 1Department of General Surgery, College of Medicine at Majmaah University, AL MAJMA’AH, Saudi Arabia; 2Department of General Surgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia., RIYADH, Saudi Arabia; 3Department of Digestive Surgery, Bariatric Surgery Center and Liver Transplant, CHU Nice, L’archet 2, NICE, France; 4Department of general surgery, Assuit university hospital, ASSUIT, Egypt

Introduction: Both obesity and life expectancy is increasing worldwide.

Objectives: The aim of the present study was to report the outcomes of bariatric surgery in patient’s = 65 years of age.

Methods: A retrospective review of prospectively collected data from patients aged = 65 years who underwent LRYGP and LSG in our institute from 2006 to 2016. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities.

Results: A total of 47 patients = 65 years (66.5 ± 0.2 years) underwent bariatric surgery in our institute. Of these 47 patients, 21 patients (44.68%) had undergone LRYGP, 20 patients (42.55%) LSG, and 6 patients (12.76%) conversion of gastric band (5 patients) and Maison (one patient) to LRYGP. The mean preoperative weight and body mass index was 109.06 ± 2.33 kg and 40.93 ± 0.74 kg/m2, respectively. The median length of follow-up was 12 months (range 1–48). The overall complications rate was 23.4%. No mortality occurred. The mean percentage of excess weight loss and body mass index was 77.5 ± 6% and 29.7 ± 1 at 12 months. The rate of resolution of diabetes mellitus, hypertension and obstructive sleep apnea syndrome was 70%, 57%, 75% and 100%respectively.

Conclusion: Bariatric surgery in carefully screened patients ± 65 years can be performed safely and can achieve improvement in co-morbidities.



C. Garraud 1, D. Lim2, S. Liu2, K. Bain2, G. Ferzli2 1General Surgery, Tuoro College of Osteopathic Medicine, BROOKLYN, United States of America; 2General Surgery, NYU Langone Hospital—Brooklyn (Lutheran), BROOKLYN, United States of America

Introduction: The preoperative workup for the bariatric patient varies from institution to institution and uncertainty exists in the literature as to the utility of certain aspects of the workup; such as routine esophagogastroduodenoscopy (EGD), screening adults and adolescence for obstructive sleep apnea (OSA), and management of asymptomatic cholelithiasis. In this submission we review the literature on controversial aspects of the bariatric preoperative workup, discuss the issues, and offer our institutional recommendations.

Methods: PUBMED search terms: ‘EGD bariatric surgery,’ ‘cholecystectomy bariatric surgery,’ ‘obstructive sleep apnea bariatric surgery’. 850 total articles were returned and 20 from each category were selected by the authors for their direct relevance to the preoperative workup before bariatric surgery.

Results: After a review of the literature, we recommend OSA screening of adult bariatric patients with an approved questionnaire and treatment with continuous positive airway pressure therapy (CPAP) for 30 days preoperatively and continuation postoperatively. We recommend against routine screening and treatment of adolescence for OSA. We recommend against synchronous cholecystectomy with bariatric procedures for asymptomatic cholelithiasis. We recommend for the use of ursodeoxycholic acid pre and postoperatively for cholelithiasis prophylaxis. We recommend for the use of preoperative EGD in mucosal altering procedures, such as the roux-en-y gastric bypass, gastric sleeve, or duodenal switch. We recommend against a routine EGD before the gastric banding. We recommend routine proton pump inhibitor (PPI) use preoperatively when symptomatic.

Conclusion: When current literature is equivocal, clinical decision making and institutional guidelines target the best preoperative workup for each bariatric patient. The recommendations for our preoperative workup and algorithm for testing is driven by our clinical experience and best interpretation of available data.



M. Wysocki1, M. Wierdak 1, M. Janik2, M. Waledziak2, P. Lech3, N. Dowigiallo-Wnukiewicz3, M. Orlowski4, H. Razak Hady5, M. Proczko-Stepaniak6, K. Major7, P. Malczak1, M. Pisarska1, J. Szeliga8, M. Pedziwiatr1, A. Budzynski1, P. Major1 12nd Department of General Surgery, Jagiellonian University Medical College, KRAKOW, Poland; 2Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, WARSAW, Poland; 3Department of General and Minimally Invasive Surgery, University of Warmia and Mazury, OLSZTYN, Poland; 4General and Vascular Surgery Department, Ceynowa Hospital, CEYNOWA, Poland; 5Department of General and Endocrinological Surgery, Medical University of Bialystok, BIALYSTOK, Poland; 6Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, GDANSK, Poland; 7Faculty of Health Sciences, Jagiellonian University Medical College, KRAKOW, Poland; 8Department of General, Gastroenterological, and Oncological Surgery, Nicolaus Copernicus University, TORUN, Poland

Introduction: The aim of this study was to investigate the influence of baseline glycated hemoglobin level (HbA1c) level in bariatric patients on postoperative outcomes. We found scarce of clinical data regarding influence of baseline HbA1c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study.

Methods and Procedures: Retrospective cohort study analyzed patients who underwent laparoscopic: sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) or mini-gastric bypass (MGB) for morbid obesity in seven referral bariatric centers. Patients were divided into groups depending on preoperative HbA1c: HbA1c < 5.7%; 5.7–6.4% and ≥ 6.5%. Primary endpoints: influence of HbA1c level on perioperative (30-days) and postoperative (12-months) morbidity rates, operation time, length of hospital stay (LOS) and readmission rate.

Results: Study group included 2125, 68% females and 32% males. Median age was 43 (35–52) years. Median HbA1c was 5.7 (5.3–6.1). HbA1c < 5.7% was present in 49% patients, HbA1c5.7–6.4% in 35%, and HbA1c ≥ 6.5% in 16%. Percentage of male patients increased in groups from 26% in HbA1C < 5.7% to 47% in HbA1C ≥ 6.5% significantly. Same tendency through groups we observed in case of BMI and age. Uncontrolled diabetes (HbA1C ≥ 6.5%) was present in 8.7% patients, while 7.62% patients were not on antidiabetic medications despite having HbA1C ≥ 6.5%. Median operative time in patients was significantly longer than in HbA1C < 5.7% and HbA1C 5.7–6.4%. 30-days morbidity rate was 5.27% and did not differ groups significantly, as 12-months morbidity rate (excl. 30-days) of 2.02% . LOS did not differ groups significantly. Patients having HbA1C in range of 5.7–6.4% and with HbA1C ≥ 6.5% did not have significantly increased odds for perioperative morbidity, 12-months postoperative morbidity as compared with those with HbA1C < 5.7%. Patients with HbA1c ≥ 6.5% had increased OR for prolonged LOS as compared to those with HbA1C < 5.7% (OR 1.45; 95% CI 1.07–1.97). HbA1c did not influence OR for readmissions. Patients with baseline HbA1c ≥ 8% had significantly increased chances for hospital readmission (OR 3.53, 95% CI 1.35–9.21).

Conclusion: Baseline level of HbA1c did not influence chance for perioperative morbidity, 12-months postoperative morbidity and prolonged LOS. Patients with HbA1c ≥ 8% have increased chance for hospital readmissions.



N. Ozlem General surgery department, Ahievran University, KIRSEHIR, Turkey

Introduction: To date, prospective comparative studies are limited that, has compared peritoneal lavage with irrigation and aspirations with the only aspiration without irrigation in perforated appendicitis.

The purpose of this study was to evaluate the effect of peritoneal lavage on postoperative complications, perioperative stay and duration of perforation in perforated appendicitis patients.

Methods: Prospectively collected data from 279 consecutive patients with acute appendicitis were studied between march 2011 to august 2012 . Perforated appendicitis was revealed in 41 patients that were randomized into two groups. Only suction was performed in group 1, and peritoneal lavage with normal saline was performed in group 2. These two groups were compared with respect to postoperative complications and length of hospital stay and operation time. Chi-squared and t-tests were used to analyze the study data.

Results: There were no differences in patient characteristics at presentation. There were no perioperative or postoperative mortalities. postoperative complications developed in 10 patients, four in group 1 and six in group 2. The overall complication rate for group 1 was 10%, compared with 15% for group 2 (p = 0.46). The overall postoperative complication rate was statistically similar for both groups. There was no statistically significant difference in the length of hospital stay, but peritoneal irrigation resulted in a longer operation time in group 2.

Conclusion: These findings revealed that there is no advantage to lavage of the peritoneal cavity over suction alone during appendectomy for perforated appendicitis.



S.A. Antoniou1, A. Andreou 2, S. Hajibandeh3, S. Hajibandeh4, S. Antoniou5, M. Weitzendorfer6, I. Daniels1, N.J. Smart1 1Surgical Service, Royal Devon & Exeter NHS Foundation Trust, EXETER, United Kingdom; 2Department of Colorectal Surgery, York Teaching Hospital NHS Foundation Trust, YORK, United Kingdom; 3General Surgery Department, Salford Royal Foundation Trust, SALFORD, United Kingdom; 4General Surgery Department, North Manchester General Hospital, MANCHESTER, United Kingdom; 5Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, MANCHESTER, United Kingdom; 6Department of Surgery, Paracelsus Medical University, SALZBURG, Austria

Aims: The best treatment option for acute complicated diverticulitis is a matter of ongoing research. We aimed to synthesize available evidence on interventions in terms of network meta-analysis.

Methods: The databases of Medline, AMED, CENTRAL, OpenGrey were interrogated. Pairwise meta-analysis for each pair of interventions was performed using a random-effects model and network meta-analysis in Stata was performed using the mvmetacommand and self-programmed Stata routines. The restricted maximum likelihood method was used to estimate heterogeneity assuming a common estimate for the heterogeneity variance across the different comparisons. Differences between direct and indirect evidence were explored by comparing direct and indirect estimates by computing the inconsistency factor within each closed loop of evidence. The contribution of each direct comparison to each of the summary estimates was computed using the contribution plot. The ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmeta command in Stata. A hierarchy of the competing interventions was obtained using rankograms.

Results: There were no significant differences in terms of mortality and morbidity among Hartmann’s procedure, laparoscopic lavage, sigmoidectomy with defunctioning loop ileostomy, and primary anastomosis, although a trend in favor of the latter in terms of mortality and morbidity was seen. Primary anastomosis had a 54% probability of being the best treatment in terms of mortality and 58% probability of being the best treatment in terms of mortality, the second best treatment being Hartmann’s procedure in terms of morbidity and laparoscopic lavage in terms of mortality.

Conclusion: Evidence on the effects of treatment strategies for acute complicated diverticulitis is still inconclusive. Primary anastomosis seems an effective option with higher probability of being the best treatment compared to Hartmann’s procedure, laparoscopic lavage, and sigmoidectomy with defunctioning loop ileostomy.



A.R.B. Kushairi, D. Igboin, N. Laskar, P. Daliya, E. Theophilidou, A. Adiamah, A. Chowdhury Department of Gastrointestinal Surgery, Queen’s Medical Centre, NOTTINGHAM, United Kingdom

Aims: Colonoscopic decompression is an effective option to definitively treat acute colonic pseudo-obstruction (ACPO). However, the availability of colonoscopy and frail condition of patients may limit the suitability of colonoscopy as a first-line option in all patients. Neostigmine, a reversible acetylcholinesterase inhibitor may effectively treat ACPO, but no up-to-date evidence supports this use. This systematic review and meta-analysis aims to investigate the use of neostigmine in treating acute colonic pseudo-obstruction as an alternative to colonoscopic decompression.

Methods: A comprehensive search of the major online databases: Medline, Embase and Cochrane databases were performed for randomised controlled trials, prospective and retrospective studies from 1946 to 2018 studying the use of neostigmine in acute colonic pseudo-obstruction. Our primary outcomes were dosage of neostigmine used, response to neostigmine, time to flatus, time to defecation, time to bowel sounds, abdominal circumference, colonic diameter, gastrointestinal motility, adverse effects of neostigmine and mortality. Quantitative pooling of data was performed using relative risk for dichotomous data with a random effects model.

Results: Eighteen studies were included in total, with 411 patients. Meta-analysis of response to neostigmine showed a significantly higher number of patients who responded to neostigmine compared to placebo [RR (95% CI) 25.98 (6.63, 101.71), P < 0.00001]. Patient response to colonoscopic decompression was greater than response to neostigmine [RR (95% CI) 1.53 (1.23, 1.91), P = 0.0001]. Qualitatively, neostigmine had a success rate of 72.7–100% in ACPO patients and was associated with shorter time to defecation. Neostigmine was associated with significant reduction in abdominal circumference and colonic diameter. Adverse effects of neostigmine were rare and no mortality related to ACPO or neostigmine was seen.

Conclusion: ACPO is a rare condition and no conclusive large trial data exists on the therapeutic effect of neostigmine on ACPO. We conclude that colonoscopic decompression is superior to neostigmine in treating ACPO, however neostigmine is an effective and safe treatment modality for ACPO in patients unsuitable for colonoscopy.



M. Fahim 1, C.S. van Kessel1, D. Smeeing1, A. Braaksma2, A. Smits1

1Department of Surgery, St. Antonis Hospital, NIEUWEGEIN, The Netherlands; 2Department of Nutrition and Health, St. Antonis Hospital, NIEUWEGEIN, The Netherlands

Introduction: Patients with bowel obstruction have chronic insufficient intake due to the stenosis as well as pain and nausea, leading to malnutrition and weight loss. Furthermore, distension of the bowel wall may lead to worse healing and an increased risk of anastomotic leakage when emergency surgery takes place. These factors may explain the high morbidity and mortality rates. The goal of this study was to examine the effect of a multimodal prehabilitation protocol aimed at preventing acute surgery and improving nutritional and physical status before elective surgery.

Methods: All patient presenting with bowel obstruction in the period 2013–2017 were included. A combination of clinical symptoms and imaging or colonoscopy was used for diagnosis. Benign and malign causes of colon obstruction were included. The protocol consisted of a combination of 1. physical training, 2. the use of oral laxatives and 3. specific dietary adjustments and residue-low nutrition.

Results: A total of 61 patients were included. 44 patients (72.1%) were treated for colorectal cancer. ASA score was moderate to severe (ASA III) in almost a fourth of the patients. Elective surgery was performed in 57 patients (93.4%). Primary anastomosis was constructed in 49 patients (86.0%). No bowel perforation, anastomotic leakages or 30-day mortality was observed. Rate of severe complications (Clavien–Dindo grade III or higher) was 6.6%.

Conclusion: Our study shows that patients with obstructive bowel disease can be safely treated with this study protocol and moreover, it results in good surgical outcome with majority of patients receiving elective laparoscopic resection with primary anastomosis and little postoperative complications. Therefore, we suggest to implement the use of this protocol for all patients with signs and symptoms of bowel obstruction.



Gy. Lázár 1, J. Tajti Jr.1, Zs. Simonka1, A. Paszt1, Sz. Ábrahám1, K. Farkas2, T. Molnár2 1Department of Surgery, University of Szeged, SZEGED, Hungary; 2First Department of Internal Medicine, University of Szeged, SZEGED, Hungary

Aim: For the surgical treatment of ulcerative colitis (UC) laparoscopy is used more widely, but limited data are available on long-term results, such as postoperative quality of life and late complications. The objective of our study is to compare the mean 64 (1–158) month follow-up results of patients treated with open and minimally invasive surgical methods.

Methods: Between 1 January 2005 and 1 December 2018 a total of 90 patients (49 women, 41 men) had undergone surgery for UC, out of which 28 (31.1%) were emergency (total colectomy with mucous fistula) and 62 (68.9%) were elective cases (proctocolectomy and ileal pouch-anal anastomosis). Laparoscopy was used in 65 (72.2%) and conventional method in 25 (27.8%) cases. Quality of life was examined with questionnaires: Functional Scoring System, Gastrointestinal Quality of Life Index (GIQLI) and Short Inflammatory Bowel Disease Questionnaire were used for testing gastroenterological conditions; Spielberger’s State-Trait Anxiety Questionnaire, Beck Depression Inventory and Brief Illness Perception Questionnaire were performed to consider psychological status.

Results: At the early postoperative period in the laparoscopic group there were significantly shorter recovery of the bowel function (1.2 vs. 1.6) and shorter length of intensive care (2.1 vs. 2.5). During the long-term follow-up, significantly fewer complications were in the laparoscopy group such as septic condition (7.6% vs. 64%), intestinal obstruction (16.9% vs. 56%) and ‘other’ complications (6.1% vs. 52%) such as hernia formation, anastomotic stenosis, per anum bleeding, and pouch-vaginal fistula. Trait anxiety was significantly lower in patients having undergone laparoscopic surgery compared with patients who had had open surgery (P = 0.018) (average value of trait anxiety in patients with open surgery was 48.71, SD = 10.91; this value was 40.22, SD = 9.82 in the laparoscopic group). The incidence of abdominal pain was significantly less common (1.895 vs. 2.769; P = 0.024) in the laparoscopic group based on the GIQLI. A significant correlation was found between the results of the psychological and gastrointestinal questionnaires.

Conclusion: Minimally invasive technique provides a better long-term outcome for patients with UC, fewer late complications and a more balanced emotional condition.



H.J. Kim, G.S. Choi, J.S. Park, S.Y. Park Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, DAEGU, Korea

Background: Lateral pelvic lymph node dissection (LPND) is a challenging procedure due to its technical difficulties and higher incidence of surgical morbidity. Owing to its technical difficulties, lateral pelvic lymph nodes (LPNs) may not be dissected completely and thus be remained in the narrow pelvis. Therefore, a steep learning curve is anticipated in doing LPND. However, no study has been conducted about the surgical acquisition of this complex procedure.

Purpose: This study was aimed to evaluate the learning process in performing robotic total mesorectal excision (TME) with LPND for patients with locally advanced rectal cancer.

Material and Methods: This study included 100 patients with rectal cancer who underwent robotic TME with LPND between 2011 and 2017. A cumulative sum analysis and moving average were performed on the basis of the number of unilateral retrieved LPNs for evaluating the learning curve.

Results: The number of retrieved LPNs steadily increased. The cumulative sum model suggested that the learning curve was divided into 4 phases based on 3 cut-off points as follows: learning I (33 patients), learning II (19 patients), consolidation (30 patients), and master (18 patients). At the beginning of the learning phase II, we started standardization of the technique and at the beginning of the consolidation phase, we adopted fluorescence-imaging. The operation time and blood loss were similar during the 4 phases. The unilateral number of retrieved LPNs was significantly greater in the master phase than in the other phases (12.8 vs. 4.9, 8.2, and 10.4, P < 0.001). Urinary problems, including urinary retention and postoperative ?-blocker use, were more frequently observed in the learning phase I than in the master phase (39.4% vs. 16.7%, P = 0.034). During the median follow-up of 44.2 months, local recurrence in the pelvic sidewall occurred in 4 patients in learning phase I and in 1 patient in learning phase II.

Conclusion: The completeness of LPND has increased after adopting the standardized surgical technique and new imaging system, and accumulation of surgeon’s experience. Further study is warranted to determine the oncologic result following each phase.



B. Mahendran, B. Rossi, S. Smolarek, N. Rajaretnam Colorectal Surgery, University Hospitals Plymouth NHS Trust, PLYMOUTH, United Kingdom

Aims: The aims of this review was to assess the effectiveness of the endoluminal vacuum system (EndoSponge) in the treatment of rectal anastomotic leaks

Methods: A comprehensive systematic search of the literature was performed in keeping with PRISMA guidelines. Records on PubMed, Medline,?Embase?and Google Scholar were searched for all relevant articles. Primary outcome was defined as the rate of anastomotic salvage, with secondary outcomes including creation of new ileostomies, ileostomy closure, additional transrectal closures, length of hospital stay, and functional outcomes. Further subgroup analysis was performed for the primary outcome, comparing early and late initiation of therapy, and neo-adjuvant radiotherapy to the field.

Results: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). All studies showed low heterogeneity (I2 = 32.09) but were of low quality with a mean MINOR score of 11.5 (SD 1.5). A total of 266 patients were included, with 202 cases operated on for a malignancy. The median treatment failure rate was 11.8% (range 0–44%), with random effects model of 0.17 (95% CI 0.11–0.22).There was significant improvement with early therapy start (OR 3.48) and negative correlation with neo-adjuvant radiotherapy OR 0.56

51% (107/210) of all diverting stomas were closed at the end of treatment period. 34/266 (12.8%) patients required an additional transrectal closure of the abscess cavity. Five studies reported functional outcomes in these patients, with different end points being used in each study. Outcomes were reported to be generally favourable amongst patients.

Conclusion: The EndoSponge works better with early initiation of therapy and in patients without pre operative radiotherapy. There is also an unexpectedly high rate of permanent ileostomies. The EndoSponge seems to be an useful method of anastomotic leak treatment in select group of patients, however the quality of available data is poor and it is impossible to draw a final conclusion. There is a need for further assessment of this therapy with well design randomised or cohort study.



K.F. Kowalewski 1, L. Seifert1, S. Ali1, M.W. Schmidt1, S. Seide2, C. Tapking1, A. Shamiyeh3, T. Hackert1, Y. Kulu1, B.P. Müller-Stich1, F. Nickel1 1General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, HEIDELBERG, Germany; 2Institute for Medical Biometry and Informatics, University Hospital of Heidelberg, HEIDELBERG, Germany; 3General and Visceral Surgery, Kepler Universitätsklinikum GmbH, LINZ, Austria

Introduction: Surgical resection is crucial for curative treatment of rectal cancer. Through improvements in treatment and minimally invasive techniques, 5-year survival improved to over 60% of patients. The most recently introduced surgical technique is robotic-assisted surgery (RAS). RAS and conventional laparoscopy (CL) seem equally effective in terms oncological control. However, RAS possibly provides further advantages e.g. 3D vision or the Endowrist function, which have the potential to maximize the precision of surgery and thus has benefits for functional outcomes such as sexual function as well continence. Therefore, the aim of this systematic review and meta-analysis was to compare functional outcomes of CL and RAS for rectal cancer.

Materials and Methods: This review was done according to the PRISMA and AMSTAR guidelines andregistered with PROSPERO(CRD42018104519). The search was planned with the PICO criteria and conducted on Medline (via PubMed), Web of Science and CENTRAL. Two independent reviewers first screened titles and abstracts and then eligible full-texts. Inclusion criteria were original studies, comparative studies for CL vs. RAS for rectal cancer as well as reporting of functional outcomes. Quality assessment was done with the Newcastle-Ottawa-Scale for non-randomized studies and the Cochrane tool to assess risk of bias for randomized trials.

Results: The search retrieved 9603 hits, of which 51 studies with 26225 patients met inclusion criteria. Preliminary results yielded a lower rate of urinary retention for RAS (Odds ratio (OR)[95%-Confidence Interval (CI)] 0.64[0.45, 0.91]) while there were no differences for ileus (OR[CI]: 0.90[0.77, 1.04]). Erectile function (IIEF) showed no differences after 3 (Mean Difference (MD)[CI] 0.80[− 1.63, 3.21], 6 (MD[CI] 1.60[− 0.69, 3.89]) and 12 months (MD[CI] 1.11[− 1.70, 3.93]). In terms of urinary problems (IPSS) there were no differences 3 postoperative (MD[CI] − 0.96[− 2.16, 0.23]) and 6 month postoperative MD[CI] − 0.92[− 1.96, 0.11]), but advantages for the CL group after 12 months MD[CI] − 1.05[− 1.89, − 0.21]).

Discussion: RAS and CL seem to provide similar functional outcomes after rectal cancer surgery. However, the results need to be interpreted carefully as none of the studies had any functional outcome defined as primary endpoint. Future studies should evaluate both surgical approaches in terms of functional outcomes and should be appropriately powered.



N.J. Rama 1, J.M. Pimentel2, P. Lopes Ferreira3, T. Jull4 1Colorectal Unit, Centro Hospitalar de Leiria, EPE, LEIRIA, Portugal; 2Colorectal Unit, CH Universitário de Coimbra, COIMBRA, Portugal; 3Centre for Health Studies and Research of the University of Coimbra (CEISUC), Faculty of Economics, University of Coimbra, COIMBRA, Portugal; 4Department of Surgery, Aarhus University Hospital, AARHUS, Denmark

Aim: We aim to perform a translation with cultural adaptation of the patient reported outcome tool, low anterior resection syndrome (LARS) Score, to the Portuguese language (LARS-PT) in the Portuguese population with rectal cancer, after proctectomy with anastomosis.

Methods: According the current international recommendations, we designed this study encompassing three main phases to validate LARS score. The questionnaire was completed by 154 patients from six Portuguese Colorectal Cancer Units, and 58 completed it twice.

Results: Portuguese version of LARS score showed a high construct validity and an internal consistency of 0.63, considered a moderate score. Regarding the test-retest, the global ICC showed a very strong test-retest reliability. Looking at all five items, only items 3 and 5 present a moderate correlation. LARS score was able to discriminate symptoms showing worse quality of life, in patients submitted to preoperative radio and chemotherapy.

Conclusions: LARS questionnaire has been properly translated into European Portuguese, demonstrating high construct validity and reliability. This tool is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation.

Keywords: Rectal neoplasms; bowel disfunction; low anterior resection syndrome score; quality of life; validation.



S. Antoniou 1, S. Tsokani2, D. Mavridis3, M. López-Cano4, D. Stefanidis5, N.K. Francis6, N.J. Smart7, F.E. Muysoms8, S. Morales-Conde9, H.J. Bonjer10, M.C. Brouwers11 1Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, MANCHESTER, United Kingdom; 2Department of Mathematics, University of Ioannina, IOANNINA, Greece; 3School of Education, University of Ioannina, IOANNINA, Greece; 4Abdominal Wall Surgery Unit, Department of General Surger, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, BARCELONA, Spain; 5Department of Surgery, Indiana University School of Medicine, INDIANAPOLIS, United States of America; 6Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, YEOVIL, United Kingdom; 7Surgical Service, Royal Devon & Exeter NHS Foundation Trust, EXETER, United Kingdom; 8Department of Surgery, Maria Middelares Hospital, GHENT, Belgium; 9Unit of Innovation in Minimally Invasive Surgery, University Hospital Virgen del Rocio, SEVILLA, Spain; 10Department of General Surgery, VU University Medical Center, AMSTERDAM, The Netherlands; 11McMaster University, McMaster University, HAMILTON, Canada

Aim: To identify clinical practice guidelines published by surgical scientific organizations, assess their quality and investigate the association between defined factors and quality. The ultimate objective was to develop a framework to improve the quality of surgical guidelines.

Methods: We searched MEDLINE for clinical practice guidelines published by surgical scientific organizations with an international scope between 2008 and 2017. We investigated the association between the following factors and guideline quality, as assessed using the AGREE II instrument: number of guidelines published within the study period by a scientific organization, the presence of a guidelines committee, applying the GRADE methodology, consensus project design, and the presence of inter-society collaboration.

Results: Ten surgical scientific organizations developed 67 guidelines over the study period. The median overall score using AGREE II tool was 4 out of a maximum of 7, whereas 27 (40%) guidelines were not considered suitable for use. Guidelines produced by a scientific organization with an output of at least 9 guidelines over the study period (odds ratio (OR) 3.79, 95% confidence interval (CI) 1.01–12.66, p = 0.048), the presence of a guidelines committee (OR 4.15, 95% CI 1.47–11.77, p = 0.007) and applying the GRADE methodology (OR 8.17, 95% CI 2.54–26.29, p < 0.0001) were associated with higher odds of being recommended for use.

Conclusion: Development by a guideline committee, routine guideline output and adhering to the GRADE methodology were found to be associated with higher guideline quality in the field of surgery.



M. Eltair 1, S. Hajibandeh2, S. Hajibandeh3 1Colorectal Surgery, Sandwell Hospital, BIRMINGHAM, United Kingdom; 2General Surgery, Sandwell Hospital, BIRMINGHAM, United Kingdom; 3General Surgery, North Manchester General Hospital, MANCHESTER, United Kingdom

Objectives: To evaluate comparative outcomes of medial-to-lateral and lateral-to-medial colorectal mobilisation in patients undergoing laparoscopic colorectal surgery.

Methods: We conducted a systematic search of electronic databases and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Perioperative mortality and morbidity, procedure time, length of hospital stay, rate of conversion to open procedure, and number of harvested lymph nodes were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

Results: We identified 8 comparative studies reporting a total of 1477 patients evaluating outcomes of medial-to-lateral (n = 626) and lateral-to-medial (n = 851) approaches in laparoscopic colorectal resection. The medial-to-lateral approach was associated with significantly lower rate of conversion to open (OR 0.43, P = 0.001), shorter procedure time (MD − 32.25, P = 0.003) and the length of hospital stay (MD − 1.54, P = 0.02) compared to the lateral-to-medial approach. However, there was no significant difference in mortality (RD 0.00, P = 0.96), overall complications (OR 0.78, P = 0.11), wound infection (OR 0.84, P = 0.60), anastomotic leak (OR 0.70, P = 0.26), bleeding (OR 0.60, P = 0.50), and number of harvested lymph nodes (MD − 1.54, P = 0.02) between two groups. Sub-group analysis demonstrated that the lateral-to-medial approach may harvest more lymph nodes in left colectomy (MD − 1.29, P = 0.0009). Removal of source of heterogeneity in sensitivity analysis showed that overall complications were lower in the medial-to-lateral group (OR 0.72, P = 0.49).

Conclusions: The medial-to-lateral approach during laparoscopic colorectal resection may reduce procedure time, length of hospital stay and conversion to open procedure rate compared to the lateral-to-medial approach. Moreover, it may probably reduce overall perioperative morbidity. However, both approaches may carry similar risk of mortality, and have comparable ability to harvest lymph nodes. Future high quality randomised studies may provide stronger evidence in favour of either approach.



A. Cossu, U. Elmore, A. Vignali, R. Rosati Gastrointestinal Surgery, San Raffaele Hospital, MILAN, Italy

Aim: To assess the safety and efficacy of single layer of barbed vs double layer ‘hybrid’ (interrupted and running) suturefor the closure of anastomotic stapler access enterotomyafter laparoscopic right colectomy with intracorporeal anastomosis.

Methods: from April 2014 to November 2018, 252 laparoscopic right colectomy with intracorporeal anastomosis were performed in our Surgical Department. All patients in both groups were perioperatively managed using an ERAS pathway. Seventy-two patients had the enterotomy closed with a single layer running suture of Filbloc ™ (Assut Europe). These patients were matched with 72 patients who underwent intracorporeal right colectomy with enterotomy closed with a ‘Hybrid’ double layer technique (first layer interrupted stitches in Maxon™ 3-0 (Covidien), second layer using a running suture in PDS™ 3-0 (Ethicon).Intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed.

Results: The two groups were homogeneous with respect to demographics, Body Mass Index (BMI), American surgical Association score (ASA) as well as for tumor stage. In the barbed group, median operating time was 121.5 min vs 140.7 min in the Hybrid group (p = 0.02). Anastomotic leak occurred in 5 (6.7%) patients in the hybrid vs 2 (2.7%) patients in the barbed group (p = 0.24) All patients required a reoperation. Intraoperative findings at shows in 2 (0.4%) cases in the Hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. No difference was observed with respect to non-infectious complications between the two groups (p = 0.55). Patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = 0.03). A re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. No patient died in the postoperative period.

Conclusion: Our results shows that the use of knotless barbed suture for enterotomy closure after laparoscopic intracorporeal right colectomy is safe, reproducible and associated with shorter operative time.



P.A. Blake, J.L. Waterman, P.N. Haray Colorectal Surgery, Cwm Taf University Health Board, MERTHYR TYDFIL, United Kingdom

Aims: The accurate measurement and staging of rectal cancer, in particular the distal margin of low rectal tumours, is of paramount importance to optimise oncological surgical resection whilst preserving function. It is well recognised that the lower the tumour, the greater the technical challenges, operative time and the possibility of a temporary or permanent stoma. Accurate localisation of the tumour is also essential to assist the multi-disciplinary team when considering neo-adjuvant chemoradiotherapy (CRTx). The objective was to compare tumour height as reported on Magnetic Resonance Imaging (MRI) with endoscopic measurement.

Methods: a retrospective analysis of rectal tumour heights on pre-operative endoscopy and MRI in patients undergoing radical colorectal surgery with curative intent over 3 years from January 2015. Rectal tumours were identified as within 15 cm of the anal verge (AV). All MRI measurements were reported by one of two specialist gastrointestinal radiologists. Measurements were taken from the lowermost point of the tumour to the AV. Endoscopic measurements were as recorded by 11 endoscopists including 2 rectal surgeons, 4 general surgeons, 4 gastroenterologists and a clinical nurse specialist endoscopist.

Results: Records of eighty one patients with histologically confirmed rectal adenocarcinoma were reviewed. Median age was 64 years (35 to 93). Twenty three patients had 2 or more endoscopies. On MRI the median tumour height from the AV was 10.75 cm (3.5–18 cm). On endoscopy the median tumour height was 23 cm (1–45 cm). On comparing endoscopy with MRI, the median difference was 12 cm (0–24 cm). For over a third of patients (36%) tumours were lower on MRI than endoscopy, median difference 12.25 cm (0.5–24 cm). Only rectal surgeons documented tumour height in relation to the rectal folds. The majority of the repeat endoscopies were performed by surgeons to locate tumours more accurately pre-surgery. On no occasion was it documented whether the tumour had been measured during insertion or withdrawal of the endoscope.

Conclusions: Precise localisation of rectal tumours is imperative to plan complex surgery and give informed counsel to patients. This study demonstrates the urgent need for a standardised protocol for all endoscopists to use while recording the distal extent of rectal tumours.



A. Costanzi 1, G. Mari1, J. Crippa2, D. Maggioni1 1General and Emergency Surgery, ASST Monza—Desio Hospital, DESIO, Italy; 2Colorectal Surgery, Mayo Clinic, ROCHESTER, United States of America

Objectives: The aim of the present RCT was to compare the incidence of genitourinary (GU) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (LAR + TME) with high or low ligation (LL) of the inferior mesenteric artery (IMA). Secondary aims included the incidence of anastomotic leakage and oncological outcomes.

Background: The criterion standard surgical approach for rectal cancer is LAR + TME. The level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. Retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on GU function is poorly understood.

Methods: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian nonacademic hospitals were randomized to high ligation (HL) or LL of IMA after meeting the inclusion criteria. GU function was evaluated using a standardized survey and uroflowmetric examination. The trial was registered under the identifier NCT02153801.

Results: A total of 214 patients were randomized to HL (n ¼ 111) or LL (n ¼ 103). GU function was impaired in both groups after surgery. LL group reported better continence and less obstructive urinary symptoms and improved quality of life at 9 months postoperative. Sexual function was better in the LL group compared to HL group at 9 months. Urinated volume, maximum urinary flow, and flow time were significantly (P < 0.05) in favour of the LL group at 1 and 9 months from surgery. Ultrasound measured post void residual volume and average urinary flow were significantly (P < 0.05) better in the LL group at 9 months postoperatively. Time of flow worsened in both groups at 9 months compared to baseline. There was no difference in anastomotic leak rate (8.1% HL vs 6.7% LL). There were no differences in terms of blood loss, surgica l times, postoperative complications, and initial oncological outcomes between groups.

Conclusions: LL of the IMA in LAR + TME results in better GU function preservation without affecting initial oncological outcomes. HL does not seem to increase the anastomotic leak rate.



A. Tanaka 1, K. Uehara1, T. Aiba1, T. Mukai1, G. Nakayama2, N. Hattori2, Y. Kodera2, M. Nagino1 1Surgical Oncology, Nagoya University Graduate School of Medicine, NAGOYA, Japan; 2Gastroenterological Surgery, Nagoya University Graduate School of Medicine, NAGOYA, Japan

Backgrounds: Chemoradiation therapy (CRT) is a standard treatment for locally advanced rectal cancer in the world. On the other hand, lateral pelvic lymph nodes (LPLN) dissection is a Japanese unique treatment for low rectal cancer. Although the technique is complicated and takes a longer operative time, the efficacies have been revised for patients with enlarged LPLNs even after CRT. Preoperative enlarged LPLN is a risk factor of lateral pelvic recurrence and enlarged LPLNs should be removed even after CRT. Colorectal surgeons should learn the technique. However, the most frequent site of LPLN metastasis occurs at the deep lateral pelvis, where is the farthest from the abdominal wall. In addition, vertical access of the forceps is unavoidable in laparoscopic surgery. Therefore, laparoscopic LPLD dissection is technically demanding.

TaTME using the access from the anus is a promising method and rapidly spread in the world. The bottom of the lateral pelvis is the farthest from the abdominal wall but nearby the anus. Using the same platform of TaTME, trans-anal LPLD dissection (TaLPLND) enabled us parallel and shortest access to the deep lateral pelvis.

Surgical technique: After TaTME, we cut the inferior pubic ligament and enter the obturator space. The dissection along the internal obturator muscle is proceeded up. The obturator nerve is securely preserved and the peripheral obturator vessels are divided. Beyond the obturator nerve, the psoas muscle and external iliac vein are confirmed. The lymphatic chain connecting to the inguinal LN is divided. At the inside of the obturator space, the dissection along the vesicohypogastric fascia between the inferior vesical vessels and obturator fat is proceeded up. At the bottom of the obturator space, the obturator vein and artery are divided. Finally, the proximal obturator fat was divided at the bifurcation of the external and internal vein.

Conclusions: This novel technique enabled us to access to the deep lateral pelvis easily. This approach has some potential advantages not only in total LPLN dissection in the difficult cases with obesity and narrow pelvis but also in picking up the enlarged LNs at the deep lateral pelvis. We show the actual technique.



M.J. Dewulf1, F.E. Muysoms 1, B. Vandenberk3, B. Defoort1, D. Claeys1, P. Pletinckx1 1General Surgery, Maria Middelares, GENT, Belgium; 2Cardiovascular sciences, UZ Leuven, LEUVEN, Belgium

Background: After the implementation of Total Mesorectal Excision (TME) in rectal cancer surgery, oncological outcomes improved dramatically. With the technique of Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL), the same surgical principles were introduced to the field of colon cancer surgery. Until now, current literature fails to invariably demonstrate its oncological superiority when compared to conventional surgery, and there are some concerns on increased morbidity. The aim of this study is to compare short-term outcomes after left-sided laparoscopic CME versus conventional surgery.

Methods: In this retrospective analysis, data on all laparoscopic sigmoidal resections performed during a 3-year period (October 2015 to October 2018) at our insititution were collected. A comparative analysis between the CME group—for left-sided colon cancer—and the non-CME group—for benign disease—was performed.

Results: One-hundred sixty-three patients met the inclusion criteria and were included for analysis. Data on 66 CME resections were compared with 97 controls. Median age and operative risk were higher in the CME group. One leak was observed in the CME group (1/66) and 3 in the non-CME group (3/97), representing no significant difference. Operative times were significantly longer in the CME group (210 versus 184 min—p < 0.001), and a trend towards longer pathological specimens in the CME group was noted (21 vs 19 cm—p = 0.059). Regarding hospital stay, postoperative complications, surgical site infections and intra-abdominal collections, no differences were observed. There was a slightly higher reoperation (6.2% versus 1.5%—p = 0.243) and readmission rate (6.2% versus 4.5%—p = 0.740) in the non-CME group during the first 30 postoperative days.

Conclusions: CME does not increase short-term complications in laparoscopic left-sided colectomies. Significantly longer operative times were observed in the CME group.



Z. Zhang1,H.R. Zhuo 2, Z. Liu3, X.S. Wang3 1Department of Surgery, Department of Environmental Health Sciences, Yale School of Medicine, Yale School of Public Health, NEW HAVEN, United States of America; 2Surgery, Yale School of Medicine, NEW HAVEN, United States of America; 3Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, BEIJING, China

Aims: Chronic obstructive pulmonary disease (COPD) is a common disorder in elderly patients. The physiologic derangement of the older patients with COPD is highly challenging and may result in postoperative complications. The aim of this study is to determine the impact of open colectomy and laparoscopic colectomy on postoperative outcomes in elderly patients with COPD.

Methods: We identified 2509 elderly patients with COPD, who were 75 years or older and underwent elective colectomy from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Colectomy Targeted database (2012–2017). Patients were excluded if they were emergent cases, or with American Society of Anesthesiologists (ASA) physical status classification of 5, ventilation requirement, sepsis, renal failure or wound infection. Multivariate logistic regression models were employed to assess the impact of different surgery types on postoperative complications. Infectious complications included four complication types of wound infection, pneumonia, urinary tract infection, and sepsis; pulmonary complications included pneumonia, pulmonary embolism, and reintubation, and cardiac complications included myocardial infarction and cardiac arrest.

Results: In the identified 1976 elderly population with COPD, 856 (43.3%) patients underwent open colectomy and 1120 (56.7%) laparoscopic colectomy. Compared to open colectomy, laparoscopic surgery was associated with decreased risk of various complications including infectious complications, pulmonary complications, cardiac complications, anastomotic leak, surgical site infection, wound dehiscence, ileus, bleeding requiring transfusion, LOS = 4 days, 30 days mortality and reoperation. After adjusting for potential confounders, significantly decreased risk associated with laparoscopic colectomy was seen for infectious complications (OR 0.41, 95% CI 0.22–0.75) and pulmonary complications (OR 0.57, 95% CI 0.40–0.83).

Conclusion: Our study suggested a decreased risk of infectious and pulmonary complications associated with laparoscopic colectomy compared to open colectomy for older patients aged 75 years or older with COPD.



F. Guerra 1, C. del Basso2, C. Coletta2 1General Surgery, AOMN—Ospedale San Salvatore Pesaro, PESARO, Italy; 2General Surgery, Policlinico Umberto I, ROME, Italy

Background: Although end colostomy closure following Hartmann’s procedure is a major surgery which is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest towards the application of different minimally invasive techniques.

Objective: We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature.

Data Sources: The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018.

Study Selection: Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques.

Main Outcomes: Measures Overall morbidity, rate of anastomotic failure, rate of wound complications, and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed.

Results: The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients in the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia.

Limitations: The lack of randomization and the presence of different reporting biases within the primary studies may have affected the general results.

Conclusions: The current evidence from the literature suggests that minimally invasive surgery should be the preferred method of performing Hartmann’s reversal.

Key-Words: Hartmann’s reversal; minimally invasive surgery; diverticular disease; end colostomy closure; meta-analysis.



S.A. Antoniou 1, N.L. Bullen1, S. Antoniou2, N.J. Smart1 1Surgical Service, Royal Devon & Exeter NHS Foundation Trust, EXETER, United Kingdom; 2Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, MANCHESTER, United Kingdom

Aim: Incisional hernia following closure of loop ileostomy is a pragmatic problem. Assessment of the incidence of this complication is limited by small sample sizes and inconsistent reporting among studies. The aim of this study was to provide an estimate of the incidence of incisional hernia following closure of loop ileostomy according to clinical and radiological diagnostic criteria and to investigate the association of bibliometric and study quality parameters with reported incidence.

Methods: A systematic review of PubMed, Embase, CENTRAL, ISRCTN Registry and Open Grey from 2000 onwards was performed according to PRISMA standards. Reporting on the type of stoma and mesh reinforcement after closure was mandatory for inclusion, whereas studies on paediatric populations were excluded. Fixed effect or random effects models were used to calculate pooled incidence estimates. Meta-regression models were formed to explore potential heterogeneity.

Results: Forty-two studies with7166 patients were included. Thepooled estimate of the incidence of incisional hernia after ileostomy closure site was 6.1% (95% confidence interval, CI 4.4% to 8.3%. Significant between study heterogeneity was identified (P < 0.001, I2 = 87%) and the likelihood of publication bias was high (P = 0.028). Mixed effects regression showed that both year of publication (P = 0.034, Q = 4.484, df = 1.000) and defining hernia as a primary outcome (Q = 20.298, P < 0.001) were related to effect size. Method of follow-up and quality of the studies also affected the reported incidence of hernia.

Conclusion: The incidence of incisional hernia at ileostomy closure site is estimated at 6.1%. Reporting incisional hernia as primary or secondary outcome, the method of diagnosis, the year of publication and methodological quality are associated with reported incidence.Registration CRD42018092400.



H. Kitamura, M. Kurokawa, T. Tsuji, D. Yamamoto, T. Takahashi, H. Bando Department of gastroenterological surgery, Ishikawa prefectural central hospital, ISHIKAWA, Japan

Aim: Fluorescent cholangiography (FC) after intravenous injection of indocyanine green (ICG) is currently a promising new technique for improved intraoperative recognition of biliary anatomy. There have been few reports on the availability of FC in laparoscopic cholecystectomy (LC) for moderate cholecystitis. We aimed to evaluate the potential of FC during LC for moderate cholecystitis.

Methods: Surgical outcomes of 100 cases (FC; n = 38, control; n = 62) that required LC for managing moderate cholecystitis during January 2009—October 2018 were analyzed retrospectively. We also reviewed video recordings of the laparoscopic procedure and analyzed the identification rate of the common bile duct, common hepatic duct and cystic duct.

Surgical procedure: Intravenous injection of 2.5 mg ICG was administered prior to the beginning of surgery. FC was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot’s triangle. LC was performed using standard procedures.

Results: The visualization rate of the common bile duct, common hepatic duct, and cystic duct using FC were 61.2%, 35.5%, and 12.9% before dissection, respectively and 93.3%, 80%, and 63.3% after complete dissection, respectively. There were no significant differences in age, sex, body mass index, acute cholecystitis and CRP between FC and control groups. Median operative time was similar in FC (117 min) and control (112 min) groups (p = 0.25). Estimated blood loss was significantly higher in FC group (50 ml versus 3 ml; p < 0.01). There was no post-operative bile leakage in the FC group, however there was one case with post-operative bile leakage that required reoperation in the control group. Abdominal abscess was observed in one patient in the FC group and four patients in the control group. Conversion to open surgery was needed for one (2.6%) patient in the FC group and six (9.7%) patients in the control group (p = 0.25). Partial cholecystectomy was performed for two (5.2%) patients in the FC group and 10 (16.1%) patients in the control group (p = 0.13).

Conclusions: FC during LC may be useful for preventing bile leakage. However, persistence to dissect Calot’s triangle using FC may increase bleeding.



L. Navaratne, J. al-Musawi, A. Isla Upper GI Surgery, Northwick Park Hospital, LONDON, United Kingdom

Aims: Laparoscopic cholecystectomy and laparoscopic CBD exploration (LCBDE) is recommended for the treatment of CBD stones with gallbladder in situ. LCBDE can be achieved by transductal (via choledochotomy) or transcystic stone extraction. The aim of this paper was to report our experience of transductal and transcystic LCBDE from over four-hundred patients.

Methods: A retrospective analysis was performed from our prospectively maintained database of 415 consecutive LCBDEs between February 1998 and December 2018. Patients were divided into two groups: transductal (TD) and transcystic (TC) LCBDE. Demographic, pre- and intra-operative data were collected. Outcome measures included successful stone clearance, mortality, morbidity, conversion to open surgery and post-operative length of hospital stay.

Results: The TD group consisted of 242 patients whereas the TC group had 173 patients. There were no significant differences in age, pre-operative bilirubin, number of CBD stones and operative times between the groups (0.09, 0.09, 0.20 and 0.38 respectively). TD group had larger CBD diameter when compared to the TC group (12.8 mm vs 10.6 mm, P < 0.0001). Holmium laser lithotripsy was used significantly more in TC stone extraction (16.8% vs 2.9% of cases, p < 0.0001). TC LCBDE was associated with higher successful stone clearance rates (99.4% vs 94.2%, p = 0.0057), less morbidity (6.4% Clavien–Dindo I–II and 1.2% Clavien–Dindo III–IV vs 21.9% Clavien–Dindo I–II and 5.0% Clavien–Dindo III–IV, p < 0.0001), less conversion to open surgery (0% vs 2.1%, p = 0.0010) and reduced post-operative length of hospital stay (median 1 vs 5 days, p < 0.0001). The incidence of post-operative pancreatitis was significantly less in the TC group when compared to the TD group (0.6% vs 7.0%, p = 0.0010). There was a trend towards a lower incidence of bile leak following TC when compared to TD stone extraction, however, this did not quite reach significance (1.2% vs 5.0%, p = 0.0504). There was no difference between the groups in mortality.

Conclusion: TC stone extraction should be considered the gold standard approach to LCBDE. TC LCBDE is associated with higher success rates and reduced incidence of post-operative pancreatitis and bile leak. The use of holmium laser lithotripsy enables higher rates of TC exploration, where the alternative would have resulted in choledochotomy.



K.F. Koeppinger, K.F. Kowalewski, L. Seifert, M.W. Schmidt, F. Lang, F. Nickel, B.P. Müller-Stich Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, HEIDELBERG, Germany

Introduction: Laparoscopic surgery has benefits for patients, for surgeons however it prolongs the learning curve. Throughout the learning curve changes of cognition occur, which lead to an improved adaption to circumstances in the operative setting. In expert surgeons these changes have become implicit knowledge. Goal of this study was to analyse the cognitive changes with regard to growing expertise.

Material and Methods: Surgeons with different levels of experience were enrolled (novices, intermediates, experts). Participants were asked to perform a standardised laparoscopic knot. The Thinking Aloud technique was used to record path of thoughts. For semantic annotation Atlas.ti software was used. Eye tracking (Pupil Labs, Germany, Berlin) was used to record number of eye movements and further parameters.

Results: With growing experience time needed for task completion decreased (novices 450 ± 242.9 s; intermediates 264 ± 29.0 s; experts 96.2 ± 13.3 s; p = 0.006). In eye tracking the total points of fixation correlated negatively with experience (novices: 4023 ± 2345; intermediates 249.3 ± 33; experts 104.3 ± 22.1; p = 0.009). Furthermore, differences not only occurred in quantitative analysis but in local distribution of view on the laparoscopic screen (img. 1). Semantic analysis of participant’s recordings showed that experts referred to standardised procedures. In the novice group however, the starting position of the needle (PN) was not controlled properly (60%) and the conclusion was not drawn until further mistrials (40%). The intermediate group already possessed the knowledge that the correct PN was necessary (80%). The ability to correctly manipulate the needle was not in the novice and the intermediate group (0%, 20%). The expert group was capable to grab the needle correctly or to reposition it properly after evaluation.

Discussion: Results show cognitive differences between experience groups. Awareness and explicit targeting of the cognitive learning procsses, which are usually implicit, seems to make training more efficient and specific. Semantic annotation and eye-tracking help to decode the steps needed to reach expertise. The used methods open opportunies to design training sessions in a way which is more cut to the individual trainee with aimed feedback and exercises dependent on the current level of experience and expertise.



J. al-Musawi 1, L. Navaratne, A. Navarro-Sanchez, A. Martinez-Isla Upper GI Surgery, Northwest London Hospitals, LONDON, United Kingdom

Aims: The use of laser has become one of the adjuncts in laparoscopic common bile duct exploration (LCBDE) for the management of large and impacted stones, as well as to increase the transcystic rate.

The aim of this work is to review the efficacy and safety of the holmium laser in our practice of LCBDE.

Methods: Between 2014 and 2018, thirty six Laser Assisted Bile duct Exploration by Laparoendoscopy (LABEL) were performed, utilising holmium laser lithotripsy, in the same period 178 LCBDE were conducted. The primary outcome measures were the success rate of transcystic stone clearance using LABEL, which may have otherwise required a choledochotomy, and the feasibility of transductal stone clearance that otherwise would have been a failure requiring postoperative ERCP. Secondary outcome measures were general and laser related complications.

Results: During the study period 36 LABEL procedures were conducted. In the same period 178 patients underwent LCBDE (in 81% the transcystic route was used). Stone clearance was achieved in all but one case. The transcystic use of LABEL avoided choledochotomy in 28 patients, and in the 8 patients who required choledochotomy its use most likely avoided failure of the LCBDE.

Within our series, 6% (2/36) of patients developed medical complications (Clavien–Dindo I and II). There were no specific complications of laser application, despite having recorded mucosal damage after lengthy lithotripsies secondary to lateral deflection of the energy.

Conclusions: The Holmium laser is a safe and valuable adjunct in LCBDE, increasing its success rate and hopefully decreasing the complications by enhancing the transcystic route.



M.K. Choudhury Laparoscopic Surgery, G I Surgery and Endo Laparoscopy Center, GUWAHATI, India

In difficult calot’s dissection during cholecystectomy, part of the gallbladder is left behind to prevent bile duct or hepatic vascular injury. The gallbladder remnant subsequently remains embedded in fibrous adhesions with the surrounding structures. So laparoscopic adhesiolysis and removal of symptomatic gall bladder remnant poses a challenge.

We are presenting our experience of laparoscopic removal of fourteen symptomatic gallbladder remnants to evaluate its feasibility and safety.

Method: Fourteen cases were operated during the period from December 2012 to november 2017. Ultrasound was the routine diagnostic investigation. MRCP was done in all the cases to know the detailed biliary anatomy.

Ports were made as in conventional lap cholecystectomy. Left sub costal port was made in selected cases where difficulty was encountered in first entry. Post operative adhesions were carefully released. Fibrous adhesions around the gall bladder remnant and in the sub hepatic area were carefully released. Energy sources like bipolar and ultrasonic scissors were useful in these situations. Gall bladder remnant was dissected out up to the Cystic duct opening. Cystic duct was either clipped or ligated before excision. Operated area was re-examined for bleeding or bile leakage and irrigated with normal saline. Drainage was applied in selected cases.

Results: Out of 14 cases (11 cases of post lap cholecystectomy, 3 cases of post open cholecystectomy) nine cases were remnant gallbladder(3 cases with acute inflammation, 1 case with acalculous cholecystitis, one with type1 mirrizzi) and five cases were cystic duct remnant(2 anomalous cystic ducts, one type1 mirrizzi)

We had one minor bile duct injury at cystic duct-CBD angle which was repaired with a t-tube drainage. Another post operative sub capsular hematoma of right lobe of liver was encountered, treated conservatively and was resolved. Pre operative ERCP was done in two cases with CBD calculi. LCBDE was done in one case simultaneously. Average hospital stay was 2–4 days.

Conclusion: Laparoscopic removal of gallbladder remnant is difficult due to fibrous adhesions with the surrounding vital structures. Expertise and the assistance of technology are required for safe removal.



A. Pesce 1, G. la Greca1, L. Esposto2, B. Basile2, S. Puleo2, S. Palmucci2 1Department of Medical, Surgical Sciences and Advanced Technologies „G.F. Ingrass, University of Catania, CATANIA, Italy; 2Department of Medical, Surgical Sciences and Advanced Technologies, University Hospital Policlinico, CATANIA, Italy

Aims: Bile duct injury (BDI) represents the most serious complication of LC, with an incidence of 0.3–0.7% resulting in a significant impact on quality of life, overall survival and frequent medico-legal litigations. Near-infrared fluorescent cholangiography (NIRF-C) represents a novel intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. The primary aim of this preliminary study was to evaluate the effectiveness of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in comparison with pre-operative magnetic resonance cholangio-pancreatography (MRCP).

Methods: Data from 26 consecutive patients with symptomatic cholelithiasis or chronic cholecistitis, who underwent elective laparoscopic cholecystectomy with intra-operative fluorescent cholangiography and pre-operative MRCP examination between January 2018 and May 2018, were analyzed. Three selected features of the cystic duct-common hepatic duct anatomy were identified and analyzed by the two different imaging methods: insertion of cystic duct, cystic duct-common hepatic duct junction and cystic duct course.

Results: Fluorescent cholangiography was performed successfully in all twenty-six patients undergoing elective laparoscopic cholecystectomy. The visualization of cystic duct was reported in 23 out of 26 cases, showing an overall diagnostic accuracy of 86.9%. The level of insertion, course and wall implantation of cystic duct were achieved by NIRF-C with diagnostic accuracy values of 65.2%, 78.3% and 91.3%, respectively in comparison with MRCP data. No bile duct injuries were reported.

Conclusion: Fluorescent cholangiography can be considered a useful, safe and low-cost imaging modality comparable to MRCP for intra-operative visualization of the cystic duct-common hepatic duct anatomy during elective laparoscopic cholecystectomies.



B.J.G.A. Corten, W.K.G. Leclercq, R.M.H. Roumen, G.D. Slooter Surgery, MMC Veldhoven, EINDHOVEN, The Netherlands

Background: The 2016 Dutch national guidelines on handling of a removed gallbladder for cholelithiasis favors a selective histopathologic policy (Sel-HP) rather than routine policy (Rout-HP). The aim of this study was to determine the current implementation of the present guideline and the daily practice of Sel-HP.

Methods: Surgeons who were engaged in gallbladder surgery and were involved in local hospitals’ gallbladder protocols completed a questionnaire study between December 2017 and May 2018. Data were analyzed using standard statistics.

Results: A 100% response rate was obtained (n = 74). Approximately 64% of all gallbladders (n = 22 500) are currently examined microscopically. Sixty-nine (93.2%) hospitals confirmed they were aware of the new guidelines, and 56 (75.7%) knew the guideline was adjusted in favor of Sel-HP. Half of the hospitals (n = 35, 47.3%) has adopted a Sel-HP, and 39 (52.7%) a Rout-HP. Of the 39 hospitals who currently practiced a Rout-HP, 36 are open to a transition to a Sel-HP although some expressed the need for more evidence on safety or novel guidelines.

Conclusions: The current implementation of the 2016 Dutch guideline advising a selective microscopic analysis of removed gallbladders for gallstone disease is suboptimal. Evidence demonstrating safety and cost-effectiveness of an on demand histopathological examination will aid in the implementation process.



A.V. Malynovskyi, M. Maiorenko, I.I. Horbachuk Department of Robotic and Endoscopic Surgery, Odessa national medical university, ODESSA, Ukraine

Aims: Intraoperative cholangiography remains the ‘gold standard’ of revision of common bile duct (CBD) for choledocholithiasis. There might be some cases of transient choledocholithiasis combined with calculous cholecystitis with a narrow or borderline diameter of CBD, including cases of hepatitis. In these cases, the probability of finding the stones in CBD is very low, and the revision of the narrow CBD may be difficult. We have invented a new application of fluorescence cholangiography (FC) for assessment of the passage of bile through CBD. According to the new method, the fluorescence of indocyanine green was detected in the initial parts of small intestine. The aim of study was to assess the specificity and sensitivity of FC for the revision of CBD.

Methods: Six patients underwent laparoscopic cholecystectomy for acute calculous cholecystitis combined with obstructive jaundice or biliary hypertension. One patient had progressive jaundice, 3 patients had transient jaundice, and 2 patients had fatty pancreatic necrosis and biliary hypertension.

Results: In 5 of 6 cases the fluorescence was detected in initial parts of small intestine, that proved normal passage of the bile. In all of these patients, the diameter of CBD was normal or borderline. In one of these cases, the jaundice subsided by the time of surgery and no revision was needed. In another 2 cases, where choledocholitiasis was combined with viral hepatitis, CBD drainage was performed via the cystic duct. The same was done for 2 patients with pancreatic necrosis. In one patient with progressive jaundice and dilated CBD, the fluorescence was not detected nether in CBD, nor in small intestine. Choledochoscopy showed stones, which were removed, and T-tube was placed. In all cases of CBD drainage, postoperative cholangiography showed no stones.

Conclusions: 1. In this limited series of cases, the new application of FC showed 100% of specificity and sensitivity in the revision of CBD. 2. FC may be sufficient to prove the absence of stones in cases of transient jaundice and narrow or borderline CBD. 3. More cases collection is needed to delignate the role of FC in revision of CBD, including comparing with intraoperative cholangiography.



M. Asakuma, R. Iida, Y. Imai, Y. Inoue, K. Koji, T. Shimizu, F. Hirokawa, K. Uchiyama General and Gastroenterological Surgery, Osaka Medical College, TAKATSUKI OSAKA, Japan

Aims: To evaluate the learning curve of Single-Port Cholecystectomy (SPC) by cumulative summation (CUSUM) analysis. As reported in Br J Surg. (2011 Jul: 98), we started performing SPC in 2009 and developed 1010 cases by December, 2018. The study addresses the need for additional data about the CUSUM learning curve of SPC, which is a relatively new procedure.

Methods: A total of 1010 SPC cases were included in this study. Cases of open conversion and port addition were excluded from the analysis. As a result, 920 pure SPC cases were evaluated by CUSUM analysis. In order to evaluate whether operative times were within the control limit, an Exponentially Weighted Moving Average (EWMA) analysis was used for each surgeon.

Results: Forty-eight surgeons took part in a total of 920 cases with a mean operative time of 89.4 ± 31 min. CUSUM analysis of each surgeon showed three phases: 20 cases in the developing phase, and 60 cases in the challenging phase were needed to reach the matured third phase. EWMA analysis showed only two of 47 surgeons were out of the upper limit of the developing phase. These two surgeons are the main developers of SPC at our institution. The operative times of the remaining 45 surgeons were within the control limit.

Conclusions: In the next decade, minimally invasive surgery will continue to change through the use of robotics, single-port, and/or reduced-port concepts. This study addresses the lack of basic data on single-port surgery. The learning curve of SPC is divided into three phases by CUSUM analysis. On average, it needs 20 cases to reach the developing phase and 60 cases to reach the matured phase, despite individual variations. A trainee will be a proctor through experience of 60 cases. According to EWMA analysis, when an institution introduces SPC, care needs to be taken as some cases may be out of the upper limit in the early phase. Properly supervised, however, SPC is a safe procedure that can be standardized.



S.H. Choi, J.W. Lee Surgery, Bundang CHA Medical Center, SEONGNAM-SI, Korea

Introduction: Robotic single-site cholecystectomy (RSSC) has been known to have some advantages such as reducing stress of the surgeon compared to single incision laparoscopic cholecystectomy (SILC). However, there are few studies comparing the perioperative outcomes of these two operative methods.

Patient and methods: Between March 2014 and February 2018, 145 RSSC and 268 SILC were performed for benign gallbladder disease in our center. Propensity score matching was performed to control variables including sex, age, body mass indes (BMI), diagnosis, American society of anesthesiologist (ASA) score and 145 cohorts were selected among the SILC group through 1:1 matching. The perioperative data of these 290 patients were analyzed retrospectively. The diagnosis was classified into acute cholecystitis, chronic cholecystitis, and gallbladder polyp.

Results: Patient demographics between the two groups were evenly matched. Total operation time including docking time was slightly longer in RSSC group (48.1 min vs. 42.6 min, P < 0.001), but real working time except the docking or set-up was shorter in RSSC group (19.2 min vs. 23.5 min, P < 0.001). Conversion to additional robotic arm or additional port was frequent in SILC group (0 vs. 5 cases, P = 0.03). Intraoperative bile spillage rate (13.8% vs. 11.7%, P = 0.725) and postoperative hospital stay (1.8 days vs. 1.7 days, P = 0.091) were comparable in both group.

Conclusion: Both surgical procedures performed safely. But the RSSC demonstrated the better performance of the operation with shorter working time and the advantage of overcoming unexpected difficulties during the surgery with low conversion rate compared to SILC.



A.V. Malynovskyi, M. Maiorenko, S.Yu. Badion Department of Robotic and Endoscopic Surgery, Odessa national medical university, ODESSA, Ukraine

Aims: The most important technical step of laparoscopic cholecystectomy (LC) is achieving ‘critical view of safety’. It may be difficult in severe acute cholecystitis with perivesicular mass, blocked gallbladder and long course of chronic cholecystitis. The aim of study was to compare fluorescence cholangiography (FC) and conventional laparoscopy for identification of anatomy in difficult LC.

Methods: FC was performed in 10 patients with severe acute and chronic cholecystitis (group 1). Conventional laparoscopy was used in 12 patients with severe acute and chronic cholecystitis (group 2). The ultrasound criteria to include the patients to group 1 were: thickening of gallbladder wall (more than 5 mm), blocked gallbladder, intrahepatic gallbladder, and perivesicular mass. The clinical criteria to include the patients to group 1 were: progressive course of acute cheolesystitis, and history of multiple attacks in chonic cholecystitis. FC was performed using Karl Storz equipment. Indocyanine green intravenous injection was done 40 min before start of dissection.

Results: The mean duration of operation was 2 h (1.5–3 h) in group 1, and 2,5 h (1.5–5 h) in group 2. The mean time to achieve ‘critical view of safety’ was 25 min (15–45 min) in group 1 and 45 min (20–60 min) in group 2. Visual analogue scales of the comfort of dissection showed better scores in group 1. No convertions and complications were observed in the both groups.

Conclusions: 1. FC allows to decrease the time to achieve ‘critical view of safety’ and duration of the entire procedure of difficult LC. 2. FC makes dissection more comfortable for surgeon in difficult LC. 2. More cases collection is necessary to determine the indications for selective use of FC.



V.V. Grubnik 1, V.V. Ilyashenko2, V.V. Grubnyk2, A.L. Kovalchuk3 1Department of surgery, Odessa medical university, ODESSA, Ukraine; 2Department of Surgery #1, Odessa medical university, ODESSA, Ukraine; 3Surgical department, Ternopil medical university, TERNOPIL, Ukraine

Aim: Of the study was to compare outcomes of primary duct closure (PDC) with and without endobiliary stent.

Methods and Procedures: For period from 2013 to 2018 laparoscopic common bile duct exploration with choledochotomy was performed in 87 patients. In 15 patients, closure of choledochus was done with T-tube drainage. PDC was performed in 72 patients. In 37 patients (I group), PDC was done with anterograde insertion of endobiliary stent and in the 35 patients (II group) without stent. There were 54 women and 18 men, age from 29 to 82 years. Mean age was 63.7 ± 12.5 years. These patients had no signs of acute biliary pancreatitis, severe acute cholangitis, and suspected biliary neoplasia. The both of group were comparable regarding sex, age, comorbidities, diameter of common biliary duct, number of concrements. The groups were evaluated according to the following criteria: postoperative complications, postoperative biliary-specific complications, re-intervention (radiology, endoscopy, and surgery), and postoperative hospital stay.

Results: There were no serious intraoperative complications in the patients of both groups. Mean operative time was 92.4 ± 22.5 min in the I group and 86.2 ± 28.6 min in the II group (p > 0.1). There were no significant postoperative complications such as postoperative bleeding, bile leakage or biliary stricture in the patients of I group. In the II group, 4 patients had bile leakage, lesions of leakage were retained stones in 3 patients and 1 patient had stricture of ampulla. Reinterventions were done in all four patients: endoscopic papillotomy—in three patients, relaparoscopy with insertion of T-tube in one patient. There were no mortalities in the patients of both groups. Mean hospital stay was 3.4 ± 1.5 days for I group and 6.5 ± 1.2 days for II group (p < 0.05).

Conclusions: PDC after laparoscopic common bile duct exploration is safe and feasible treatment modality. In the cases with multiple common bile duct stones and ampulla stenosis, anterograde insertion of endobiliary stent prevent biliary leakage.



A. Ali, A. Saha Dept of GI, HPB, Bariatric & Minimal Access Surgery, Venkateshwar Hospital, NEW DELHI, India

Aims: To check the feasibility of Laparoscopic Choledochoduodenostomy (LCD) for failed ERCP as well as a rescue procedure for intraoperative complications.

Patients & Methods: Fourteen patients underwent choledochoduodenostomy between April 2016 and November 2018. Eight underwent Open Choledochoduodenostomy (OCD) and six underwent LCD. Four had Gallstones alongwith Common Bile Duct (CBD) stones, while one had CBD stones presenting 5 years after Laparoscopic Cholecystectomy. One patient had a duodenal injury during a difficult dissection for Laparoscopic CBD exploration (LCDE). All patients had undergone a preoperative MRCP and an ERCP that failed to clear the CBD of stones, and a stent was placed. All patients had a CBD diameter of not less than 1.5 cm. OCD were performed through a Kocker’s incision. LCD were done using 4–5 ports. A 24 Fr abdominal drain was placed in all cases, and removed at discharge.

Results: All patients were started on liquids next day of surgery. There were no anastomotic leaks, no bile collections. One OCD patient has a superficial surgical site infection. All LCD cases were discharged on day 3 post op and OCD were discharged between post-op day 3 and 5.

Conclusion: LCD is feasible and desirable in cases of large impacted CBD stones where ERCP has failed. At times, LCD can be used as a rescue procedure for some duodenal injuries during hepato-biliary surgeries.



O.I. Lytvyn, P.V. Ogorodnik, A.G. Deinychenko, N.A. Yermak, O.I. Lytvyn Laparoscopic surgery, National institute of surgery and transplantology, KYIV, Ukraine

The treatment of patients with bile duct stones is in a stage of evolution. In cases of difficult bile duct stones ordinary endoscopic methods (ERCP/balloon-basket extraction) fail. This study aimed at comparing the success rate and complications between mechanical lithotripsy (ML) and large balloon dilation (LBD) after endoscopic sphincterotomy.

Patient and Methods: Over a 8—year period, from 2010 to 2018, 1257 patients presented with difficult bile duct stones. The patients were divided into 2 groups : group A comprising 1120 patients treated by ML and group B comprising 137 patients treated by LBD. All patients underwent endoscopic sphincterotomy initially.

Results: Stones larger than 15 mm, square-shaped stones, multiple bile duct stones and hard stones were observed in 718 cases. Anatomical variations which makes accessibility to the papilla challenging such as the presence of periampullary diverticulum, altered anatomy, narrow distal bile duct, duodenal or bile duct stricture occurred in 539 cases. The success rate for bile duct clearance was 92.5% and 94% for ML and LBD, respectively. The overall complication rate in this study was 10.8%. The complication rate was 8.1% and 12.5% for LBD and ML, respectively. Patients treated by LBD, after EST, were prone to less adverse events than patients treated by lithotripsy after sphincterotomy and the difference was statistically significant (P = 0.04).

Conclusion: The LBD and ML are both acceptable in the treatment of patients with difficult bile duct stones. Endoscopic sphincterotomy followed by LBD is a safe and effective treatment for difficult bile duct stones in comparison with sphincterotomy followed by ML.



Y.Y. Liu General surgery, Chang gung memorial hospital kaohsiung division, KAOHSIUNG, Taiwan

Purpose: Laparoscopic cholecystectomy(LC) is the one of most common procedure done by minimal invasive surgery worldwide but the common bile duct(CBD) injury still happened, especial in cholecystitis. Image guided surgery created new concept for fluorescent cholangiography to demonstrate the anatomy of CBD by using indocyanine green (ICG) intravenous injection before operation to decreased complication. The result is positive but the border of gallbladder can’t be seen very well in systemic injection . In cholecystitis, the border between gallbladder and common bile duct is important as well as CBD and cystic duct. We hypothesized injection of ICG into gallbladder directly will be helpful to identify cystic duct, CBD and the border of gallbladder as well as systemic injection . The purpose of this study was to evaluate feasibility of this image guide surgery

Material and method: This is a IRB proven prospective study. Total 120 patients were involved this study. Arm 1: ICG injected via Gallbladder; Arm 2: ICG injected via IV access; Arm 3: control. Three laparoscopic ports were introduced and the pneumoperitoneum (12 mmHg) was established. A near-infrared optimized laparoscope was used to detect the ICG fluorescence signal arising from gallbladder, cystic duct and common bile duct before cholecystectomy . According to the enhancement of ICG, the cholecystectomy was started from cystic duct in Calot’s triangle. Time to gallbladder removed was recorded. Conversion rate, post-operative morbidity and mortality will be recorded as well .

Results: Overall, in all the patients divided into arm 1,2,3, the Hartman pouch was identified in 92.89, 75% of cases, the cystic duct :84.7, 55, 3, 45%, the CBD in 78.2, 90, 60,3%, and the CHD 63, 83.3, 33%. No conversion, mortality and major complication including post-op bile leak in our study. Wound infection rate was 0.5% Median days for admission was 3.45 days.

Conclusions: Clinical translation of near-infrared fluorescence cholangiography has been successful with a visualization of biliary anatomy no matter injection from gallbladder or systemic circulation. It can be considered in difficult cases to increase the safety of laparoscopic cholecystectomy.



M. Bouassida, S. Zribi, G. Laamiri, I. Ben Smail, S. Sassi, M.M. Mighri, H. Touinsi Department of Surgery, Mohamed Tahar Maamouri Hospital, NABEUL, Tunisia

Aims: The 2018 Tokyo guidelines for acute cholecystitis (AC) use white cell count (WCC) as one of the severity criteria.

The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WCC for the severity of AC, and the risk for conversion to open cholecystectomy and to determine their diagnostic cutoff levels.

Methods: This was a retrospective cohort study. Over 5 years, 556 patients underwent laparoscopic cholecystectomy for AC. There were 139 advanced AC (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 non advanced AC. The conversion rate to open cholecystectomy was 13.5%.

Results: Predictive factors for advanced AC, in multivariate analysis were: body temperature (OR 2.8 [1.3–6]), CRP (OR 1.01 [1.004–1.015]), diabetes (OR 5.6 [1.44–22]).

Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in diagnosing advanced AC. Values of WCC for diagnosing advanced AC were equal to or above 12.1 ± 109/L (Se = 64%, Sp = 65%), NLR 3.87 and above (Se = 62%, Sp = 62.5%), and CRP concentration 60.5 mg/L or above (Se = 71%, Sp = 71.4%).

CRP was the only predictive factor for conversion in multivariate analysis (OR = 1.008 [1.003–1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in term of conversion. Values of CRP for predicting conversion were equal to or above 76 mg/L or above (Se = 66%; Sp = 66%).

Conclusions: CRP is the only inflammatory marker predictive for advanced AC and for conversion to open cholecystectomy. CRP had the highest discriminative power in diagnosing advanced AC with a good sensitivity (71%) and specificity (71%).

We think that CRP should be considered as a severity criteria of acute cholecystitis instead of white cell count.



Mohamed S. Salama 1, Mahmoud S. Salama2, B. Eoghan1, S. Babur1, A. Ibrahim1, A.R. Nasr1 1Surgery, Our lady of lourdes hospital, BETTYSTOWN, Ireland; 2Medical student, Trinity college, DUBLIN, Ireland

Introduction: Surgical Site Infection (SSI) impacts patient’s morbidity, mortality and adversely impacts health care costs. It is used as a surrogate for quality and performance. Its incidence varies widely between hospitals and between surgeons (2.5–42%) with NICE estimating an average SSI rate of 5%. It is crucial for each healthcare system to conduct SSI surveillance.

Aim: To quantify wound infection rate and risk factors for SSI in our hospital post elective laparoscopic cholecystectomy (LC) or hernia surgery (HS).

Methods: A prospective study was conducted from 01/04/2016 to 31/12/2016. All patients admitted for elective LC or HS were recruited. The surveillance methodology was based on National Healthcare Safety Network (NHSN) methods. A 30 and 90 day post discharge surveillance period was used for LC and HS respectively. Data collected preoperatively included: age, gender, BMI, co-morbidities, ASA score, surgical technique, admission, surgery and discharge dates.

Results: The total patient cohort numbered 257 (LC 112 & HS 145). In total 7 patients developed SSI (LC 3 & HS 4) giving a rate of 2.7%.

Of 6 diabetic patients undergoing LC one developed a SSI and of the 9 diabetic patients undergoing HS one developed a SSI. In contrast, of the 101 non-diabetic patients undergoing LC two developed SSI, and of the 133 non-diabetic patients undergoing HS three developed SSI. 8 patients’ diabetic status was not documented.

Of the 26 obese patients undergoing LC two developed a SSI and of the 20 obese patients undergoing HS one developed a SSI.

Compliance with preoperative antibiotic timing (within 60 min prior to incision) was 69%. SSI was observed in 3 LC & 2 HS when antibiotics were administered > 60 min. SSI was observed in 0 LC & 2 HS for antibiotics administered < 60 min.

Compliance with correct preoperative antibiotic choice was 71%. SSI was observed in 1 LC & 1 HS with correct antibiotic choice and 1 LC & 2 HS in non-compliant group.

Conclusion: Every hospital should continuously monitor and audit SSI rates. We aim to improve our SSI rate by adopting zero tolerance to non-compliance with timing and choice of prophylactic antibiotics.



T. Yoo, W.T. Cho Surgery, Dongtan Sacred Heart Hospital Hallym University College of Medicine, HWASUNG-SI, Korea

Even though laparoscopic cholecystectomy(LC) is the gold standard procedure for cholelithiasis, patients are still suffering from various causes of pain. one of main causes is high pressure by pneumoperitoneum which makes peritoneal stretching and diaphragmatic irritation. However, there are few well-designed studies for evaluating pneumoperitoneum.

Therefore, we conducted a study to compare the postoperative pain after LC at serial different pressure methods. A prospective randomised double blind study was done in 147 patients with benign gallbladder disease. They were divided into 3 groups. Each 49 patients underwent LC with different pneumoperitoneum method; Group A: far-low (6–8 mmHg), goup B: low (9–11 mmhg) and group C: standard pressure (12–14 mmHg). Three groups were compared for pain intensity, duration, analgesic requirement and complications. Post-operative pain score was significantly least in far-low pressure group as compared to low or standard pressure group during late periods (12, 24 h). But, there were no pain score difference between far-low and low groups during early period (1, 2, 4, 8 h) even though scores of standard group were significant higher than those of low group. Number of patients requiring rescue analgesic doses and intraoperative complications were not significantly different among 3 groups.

This study demonstrates reducing the pressure of pneumoperitoneum results in reduction in intensity of post-operative pain. This study also shows that low pressure technique is safe with comparable rate of intraoperative complications. However, in immediate postoperative period, there is limitaton of pain relief after low pressure surgery. Therefore, there may need new alternatives for pain.



T. Ikeda, K. Kimura, K. Kudo, S. Okano Center for Advanced Medical Innovation, Kyushu University, FUKUOKA, Japan

Background and aim: Anatomical hepatectomy with the Glissonian approach is widely accepted as an important technique to ensure surgical safety and curability of the carcinoma. However, the histomorphological structure of the hepatic connective tissue is not sufficiently understood by surgeons. This study aimed to clarify the hepatic connective tissue structure using modern tissue imaging and analytical techniques.

Materials and methods: In total 5000 stained thin slices were loaded onto the computer and were reconstructed as 3Dimages and analyzed.

Results: When the liver capsule enters the liver at the hepatic hilum, it becomes a sheath which envelops the portal pedicle. The hepatocytes in a row that constitute the periportal limiting plate at the edge of the hepatic lobule are firmly supported by the framework of the reticular fiber. The hepatic lobule and the portal area are in contact via the periportal space of Mall. The framework of the limiting plate plays a role of a capsule of hepatic lobule (proper hepatic capsule) on the side in contact with the portal area. The binding site between the hepatic capsule and proper hepatic capsule (PPBS) is loose binding and is a layer that is easy to apply to surgical procedures.

In order to enter between the liver capsule which became the sheath of the portal pedicle and the proper hepatic capsule at the hepatic hilum, the liver capsule must be dissected to reach the surface of the proper hepatic capsule. Then, on the one hand, the portal pedicle is firmly gripped and pulled, on the other hand, the hepatic parenchyma covered by the proper hepatic capsule is pushed to expand between the portal pedicle and the liver parenchyma. At this time, the portal area (Glisson’s sheath) branched from the sheath of the portal pedicle into the gap of the hepatic lobule breaks like a string. With this dissecting plane, dissecting layer can reach to the next branch of the portal pedicle without entering into the portal pedicle or liver parenchyma.

Conclusion: Understanding the connective tissue constituting the liver and conducting surgery turns the laparoscopic systematic hepatectomy into a standardized procedure.



U. Cillo 1, A. Bertacco1, E. Gringeri1, E. Fasolo1, L. Aldrighetti2, A. Guglielmi3, V. Mazzaferro4, A. Ferrero5, S. Gruttadauria6, F. Calise7, U. Boggi8, F. Giuliante9, E. Jovine10, G. Belli11, G. Torzilli12, A. Frena13, F. Farinati14, F. Trevisani15

1Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation, Padua University, PADUA, Italy; 2Ospedale San Raffaele-U.O. Chirurgia Epatobiliare, MILANO, Italy; 3A.O.U. Integrata Verona—Policlinico G.B. Rossi—Chirurgia Generale ed Epatobi, VERONA, Italy; 4Fondazione IRCCS Istituto Nazionale dei Tumori—S.C. Chirurgia generale indiriz, MILANO, Italy; 5Ospedale Mauriziano Umberto I-S.C. Chirurgia Generale ed Oncologica, TORINO, Italy; 6IsMeTT-U.O. Chirurgia Addominale e Trapianti Addominali, PALERMO, Italy; 7A. Cardarelli„-Chirurgia Epatobiliare e Centro Trapianti di Fegato, NAPOLI, Italy; 8A.O.U. Pisana- U.O. Chirurgia generale e trapianti, PISA, Italy; 9A.Gemelli-U.O.C. Chirurgia Epatobiliare, ROMA, Italy; 10Ospedale Maggiore AUSL Bologna-Chirurgia generale A e d’urgenza, BOLOGNA, Italy; 11Ospedale S. M. Loreto Nuovo-ASL NA1 Centro- U.O. Chirurgia Generale ed Epatobili, NAPOLI, Italy; 12Istituto Clinico Humanitas-U.O.C. Chirurgia Epatobiliare, ROZZANO, Italy; 13Ospedale Centrale-S.S. Chirurgia Epatobiliare, BOLZANO, Italy; 14Department of Surgery, Oncology and Gastroenterology, Padua University, Padua, PADOVA, Italy; 15Dipartimento di Scienze Mediche e Chirurgiche, Department of Medical and Surgical Sciences Division of Semeiotics, Alma Mater S, BOLOGNA, Italy

Background: TACE represents the most widely used first line treatment across all disease stages. It represents, in general, the recommended treatment modality for BCLC B patients although this stage includes a very heterogeneous patient populationThe aim of this study is to compare outcome of laparoscopic liver resection (LLR)vs transarterial chemoembolization (TACE) in intermediate stage HCC patients.

Methods: Data of HCC patients treated with LLR at 13 Italian centers were analyzed and compared with those treated with TACE included in the ITA.LI.CA database in the period 2014–2017. Only BCLC B HCC patients were considered for the analysis: a propensity score analysis was used to match LLR and TACE patients.

Results: 52 HCC patients underwent LLR; patients treated with TACE in the same period were 124. No difference in overall survival (OS) was found between the groups (p = 0.691) while proportion of recurrence was significantly lower in the LLR (p = 0.003). After propensy score analysis (40 patients each group) LLR provided 1, 3 and 5 year OS of 97.1%, 93.8% and 82.1% that resulted statistically significant (p = 0.020) compared to TACE. Tumor recurrence, again, resulted significant between groups (p = 0.087). At the multivariate analysis LLR (HR 0.2) positively impacted survival while portal hypertension (HR 6.6) was found independently associated with a worse outcome.

Conclusions: The beneficial effect of LLR in term of survival and recurrence remains also in BCLC B patients when compared to TACE



D. Aghayan 1, P. Kalinowski2, A. Kazaryan3, Å. Fretland4, M. Sahakyan1, E. Pelanis1, B. Røsok4, B. Edwin1 1The Intervention Centre, Oslo University Hospital, OSLO, Norway; 2Department of General, Transplant and Liver Surgery, Medical University of Warsaw, WARSAW, Poland; 3Department of General Surgery, Fonna Hospital Trust, STORD, Norway; 4Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, OSLO, Norway

Background: Liver resection is a treatment of choice for colorectal and neuroendocrine liver metastases and laparoscopy is an accepted approach for surgical treatment of these patients. The role of liver resection for patients with non-colorectal non-neuroendocrine liver metastases (NCNNLM), however, is still disputable. Outcomes of laparoscopic liver resection for this group of patients have not been analyzed.

Material and methods: In this study, patients who underwent laparoscopic liver resection for NCNNLM at Oslo University Hospital between April 2000 and January 2018 were analyzed. Perioperative and oncologic data of these patients were examined. Postoperative morbidity was classified using the Accordion classification. Kaplan-Meier method was used for survival analysis. Median follow-up was 26 (4–109) months.

Results: Fifty-one patients were identified from a prospectively collected database. The histology of primary tumors was classified as adenocarcinoma (n = 16), sarcoma (n = 4), squamous cell carcinoma (n = 4), melanoma (n = 16), gastrointestinal stromal tumor (n = 9) and adrenocortical carcinoma (n = 2). The median operative time was 147 (30–470) min, while the median blood loss was 200 (20–4000) ml. Nine (18%) patients experienced postoperative complications. There was no 90-day mortality in this study. Thirty-five (68%) patients developed disease recurrence or progression. Seven (14%) patients underwent repeat surgical procedure for recurrent liver metastases. One-, three- and five-year overall survival rates were 85%, 52% and 38%, respectively. The median overall survival was 37 (95% CI 25 to 49) months.

Conclusion: Laparoscopic liver resection for NCNNLM results in good outcomes and should be considered in patients selected for surgical treatment.



T. Igami Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, NAGOYA, Japan

Background: Laparoscopic hepatectomy for an invisible small tumor even by intraoperative ultrasonography is technically demanding. In such situation, intrahepatic vessels are recognized as important indicators of determination of resection area and preoperative 3D liver images reconstructed by MDCT are utilized as surgical assist. We are going to try development of real-time navigation system for laparoscopic hepatectomy, which resembles a car navigation system. We report our real-time navigation system and surgical procedure.

Methods: Virtual 3D liver and body images are reconstructed using ‘New-VES’ system developed by Nagoya University Graduate School of Information Science—Mori’s Office. These images correspond to maps of car navigation system. Some of patient’s body parts are registered in virtual 3D liver and body images using a magnetic position sensor. Patient’s body after registration corresponds to The Earth. A transmitter for magnetic position sensor, which corresponds to an artificial satellite, is placed about 30 cm above patient’s body. A micro magnetic sensor, which corresponds to GPS antenna, fixes on the handling part of laparoscope. Laparoscopic hepatectomy is performed using both real operative and virtual monitors.

Fiducial registration error (FRE, which means an error between real operative and virtual lengths) is utilized to evaluate accuracy of real-time navigation system.

Results: e performed laparoscopic hepatectomy using this system in 21 patients. Mean FRE of initial 5 patients was 17.7 mm. First improvement was that MDCT were taken using radiological markers for registration of body parts. Mean FRE of the 8 patients who utilized first improvement was 10.2 mm and decreased (p = 0.014). Second improvement was that a micro magnetic sensor as an intraoperative body position sensor was fixed on the right-sided chest wall and meant that pre- and post- operative FRE was similar due to an intraoperatively automatic correction of gap of body position. Preoperative and postoperative mean FRE of the 8 patients who utilized second improvement were 11.1 mm and 10.1 mm. Those mean FRE were statistically similar (p = 0.250).

Conclusions: Our real-time navigation system can assist laparoscopic hepatectomy. However, FRE is still large margins; therefore, further improvement of our system is necessary to represent an alternative to an intraoperative ultrasonography.



P. Ypsilantis1, O. Ioannidis 1, M. Lambropoulou2, C. Anagnostopoulos3, A. Totsi1, C. Zervas1, C. Simopoulos1 1Laboratory of Experimental Surgery and Surgical Research, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece, ALEXANDROUPOLIS, Greece; 2Laboratory of Histology and Embryology, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece, THESSALONIKI, Greece; 3Laboratory of Biochemistry, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece, THESSALONIKI, Greece

Aims: To compare laparoscopic versus open partial hepatectomy with regards to the regenerating activity, oxidative state, inflammatory response and histopathologic profile of the remnant liver tissue.

Methods: Ninety six Wistar rats were subjected to excision of the left lateral and the median hepatic lobes either laparoscopically (group LAP-HEP) or after midline laparotomy (group HEP), sham operation (group Sham) or no operation (group Control). At various timepoints post-operatively (1 h—2 w) the relative liver weight, mitotic index (SER-10 antibody), oxidative state (TBARS levels), inflammatory response biomarkers (NF?B, ICAM-1 and VCAM-1) and the histopathologic index were assessed in the remnant liver parenchyma.

Results: Although relative liver weight did not differ between the hepatectomy groups, the mitotic index was higher in group LAP-HEP compared to group HEP. TBARS levels were increased in group LAP-HEP. VCAM-1 expression was more intense in group LAP-HEP compared to group HEP, whereas NF?B was equally overexpressed in the study groups and ICAM-1 in the hepatectomy groups. At 24 h, histopathologic index was higher in group HEP than that in group LAP-HEP.

Conclusions: Laparoscopic partial hepatectomy conferred a more intense mitotic effect and oxidative stress, while a less pronounced inflammatory response and deterioration of the histopathologic profile of the remnant liver tissue than that of the open technique.



F. Ratti, F.C. Cipriani, G.F. Fiorentini, M. Catena, M. Paganelli, A.L. Aldrighetti Hepatobiliary Surgery Division, San Raffaele Hospital, MILANO, Italy

Background: Implementation of minimally invasive liver resection (MILS) programs starts, in a stepwise fashion, from procedures with a low degree of technical difficulty, given the higher feasibility at the beginning of the educational pathway. In this perspective, the strength of commitment to MILS is generally based on its feasibility, rather than on its benefit compared with open approach. Aim of the present study is to evaluate the differential benefit of laparoscopic over open technique according to the technical difficulty of the procedures and to define—according to this parameter—the strength of commitment to minimally invasive approach.

Material and methods: 936 MILS resections performed between 2005 and 2018 were stratified according to technical complexity (Low, Intermediate and High difficulty) and to approach (MILS or open) and then matched in a 1:1 ratio using propensity scores to obtain three pairs of groups (Pair 1:Low-MILS and Low-Open, including 274 cases respectively; Pair 2: Int-MILS and Int-Open, including 237 patients respectively; Pair 3: High-MILS and High-Open, including 226 patients respectively). Blood loss, postoperative morbidity and time for functional recovery were chosen as outcome indicators to calculate the differential benefit among pairs.

Results: MILS approach resulted in a statistically significant lower blood loss, reduced morbidity, reduced and shorter time for functional recover and length of stay within all pairs. Reflecting different degree of complexity, procedures showed significantly different blood loss, morbidity, rate of conversion and time for functional recovery among different Pairs. The evaluation of the differential benefit showed a greater advantage of laparoscopic approach in High degree procedures compared with Intermediate and Low degree, both in terms of blood loss (− 250 mL and − 200 mL respectively) and morbidity rate (− 5.7% and − 4.1% respectively).

Conclusion: The favorable biological scenario associated with laparoscopic approach allows to obtain significant benefits in the setting of technically complex procedures, constituting the prerequisite for an adequate surgical outcome. The commitment towards MILS approach should be therefore stronger in this setting, where—overcome the limit of technical challenges—the advantage of laparoscopy seems to be enhanced.



Y.S. Han 1, J.R. Han1, H.T. Ha1, J.M. Chun2 1Hepatobiliary Pancreas Surgery and Liver Transplantation, Kyungpook National University, School of Medicine, DAEGU, Korea; 2Liver Transplantation, Kyungpook National University, School of Medicine, DAEGU, Korea

Purpose: Although laparoscopic liver resection has progressively developed with increased surgical experience and the improvement of laparoscopes and specialized instruments, Only a limited number of centers have performed laparoscopic living donor hepatectomy to date because of concerns about donor safety,graft outcome and the need for expertise in both laparoscopic liver surgery and living donor liver transplantation(LDLT). For these reason, a totally laparoscopic living donor right hepatectomy (LDRH) technique has not been investigated for efficacy and feasibility. We describe the experiences and outcomes associated with LDRH in adult-to-adult LDLT in order to assess the safety of the totally laparoscopic technique in donors.

Methods: Between December 2014 and October 2018, we performed 97 cases of living donor right hepatectomy. Among them, 50 donors underwent totally laparoscopic living donor right hepatectomy and 47 donors underwent conventional open living donor right hepatectomy. We retrospectively reviewed the medical records to ascertain donor safety and the reproducibility of LDRH; intra-operative and post-operative results including complications were demonstrated after performing LDRH.

Results: The total operation time was longer (367.0 ± 74.3 vs 323.5 ± 62.5; P = .002) and the warm ischemic time was also longer (9.2 ± 4.6 vs 1.8 ± 1.6; P < .002) in LDRH group. However, the length of postoperative hospital stay was similar in both groups and no donors in LDRH group required blood transfusion, conversion to open surgery, or reoperation. There was no postoperative mortality. Postoperative complication of Clavien-Dindo classification III or more in LDRH group was identified in only one donor who had a minor bile leakage from the cutting edge of the right hepatic duct stump requiring endoscopic biliary stent insertion. All the liver function tests returned to normal ranges within 2 weeks.

Conclusion: In conclusion, our study reveals LDRH seems to be a safe and feasible procedure with acceptable outcomes. However, LDRH can be initially attempted after attaining sufficient experience in laparoscopic hepatectomy and LDLT techniques.



J.H. Kim Department of Surgery, Eulji University Hospital, DAEJEON, Korea

Aims: Laparoscopic major hepatectomy is a technically challenging procedure and needs a steep learning curve. The liver hanging maneuver is a useful technique in liver surgery, especially in the case of large tumors or invasive tumors which is relatively contraindications for laparoscopic liver resection. The present study aimed to evaluate the learning curve and the evolution of indications for laparoscopic major hepatectomy using the modified liver hanging maneuver.

Methods: From January 2013 and September 2018, we retrospectively reviewed patients who underwent laparoscopic major hepatectomy using the modified liver hanging maneuver by a single surgeon. Our hanging technique involves the hanging tape was placed along the lateral side of inferior vena cava for right-sided hepatectomy or the ligamentum venosum for left-sided hepatectomy. The learning curve for operating time and blood loss was evaluated using the cumulative sum (CUSUM) method.

Results: Of the 53 patients, 18 patients underwent right hepatectomy, 26 underwent left hepatectomy and 9 underwent right posterior sectionectomy. CUSUM analysis showed that operative time and blood loss improved after the 30th laparoscopic major hepatectomy. These 53 consecutive patients were divided into two groups (early group: 1–30 cases, late group: 31–53 cases). The median operation time was decreased in the late group, but the difference was not statistically significant (270 vs. 245 min, p = 0.261). The median blood loss was significantly lower in the late group (350 vs. 150 ml, p < 0.001). The large tumors (greater than 10 cm) and tumors in proximity to major vessels were significantly higher in late group (0 vs. 17.4% p = 0.018, 3.3 vs. 21.7% p = 0.036, respectively). The tumors invading adjacent organ was higher in the late group, but the difference was not statistically significant. (0 vs. 8.7%, p = 0.100).

Conclusion: This study shows that laparoscopic major hepatectomy has a learning curve of 30 cases. The step-wise training and standardized procedure of the modified liver hanging maneuver may shorten the learning curve. After standardization of our procedure, the indications have gradually been extended to large tumors or invasive tumors.



B.K. Goh Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, SINGAPORE, Singapore

Background: Several studies published mainly from pioneers and early adopters have documented the evolution of minimally-invasive hepatectomy(MIH). However, questions remain if these reported experiences are applicable and reproducible today. This study examines the changing trends, safety and outcomes associated with the adoption of MIH.

Methods: Retrospective review of 500 consecutive patients who underwent MIH between 2006–2018 of which 460 cases (92%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into 5 equal groups of 100 patients. Analyses was also performed of predictive factors and outcomes of open conversion.

Results: Five hundred patients underwent MIH of which 479 (97.8%) were totally laparoscopic/robotic. 118 (23.6%) patients underwent major hepatectomy and 199 (39.9%) had resection of tumors located in the posterosuperior segments. 32 patients (6.4%) had previous liver resections. There were 45 (9.0%) open conversions. Comparison across the 5 groups demonstrated that patients were older, had higher ASA score, had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of = 3 segments and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time and increased use of Pringles maneuver. Presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity and mortality.

Conclusion: The case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes.



V. Ferri, E. Vicente, Y. Quijano, D. Hipolito, B. Ielpo, E. Diaz, I. Fabra, L. Malave, R. Isernia, E. Pinna, R. Caruso General Surgery, Sanchinarro University Hospital, MADRID, Spain

Introduction: The robotic surgery cost presents a critical issue which has been investigated only in few studies. In the literature there is not any study which evaluate the cost-effectiveness of the robotic distal pancreatectomy (RDP) over de laparoscopic distal pancreatectomy (LDP).

We have therefore performed a prospective comparative study of RDP and LDP performed at our centre with the aim to evaluate clinical and the cost-effective outcomes.

Matherial and methods: This is an observational, comparative prospective non-randomized study which includes patients that underwent RDP and LDP reaching a minimum of 6 months of follow up from February 2014 to March 2018, at the Sanchinarro University Hospital, Madrid. An independent company performed the financial analysis. Outcome parameters included surgical and post-operative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER). The primary end-point was to compare the cost effectiveness differences between both groups.

Results: A total of 35 RDP and 31 LDP have been included. Conversion rate resulted to be significative higher in the LDP (3.6% vs 19.2%; p = 0.04). The overall rate of pancreatic leak was 10.7% in the RDP group and 15.4% in the LDP group (p > 0.5). The mean number of hospital stay days was significative higher in the LDP (8.9 days vs 16.9 days, p = 0.03). The mean operative time was higher in the RDP

(294 vs 241 min; p = 0.02). The overall mean total cost was similar in both groups (RDP: 9198.64€ versus LDP: 9399.74€; P > 0.5). Mean QALYs at 1 year for RDP (0.622) was higher than that associated with LDP (0.60025) (p > 0.5). At a willingness-to-pay threshold of 20,000 € and 30,000 €, there was a 63.58% and 76.69% probability that RDP was cost-effective relative to LDP.

Conclusion: This study provides data of cost-effectiveness between RDP and LDP approach showing benefit for the RDP.



C.M. Peng, Y.K. Yang General Surgery, Da Vinci MIS Center/Chung Shan Medical University Hospital, TAICHUNG, Taiwan

Purpose: The right hepatic artery (RHA) is the most common hepatic artery (CHA) variation. This variation may be problematic in in open, laparoscopic or robotic pancreaticoduodenectomy (PD). The vascular configuration described as normal is found in only 55–75.5% of cases, which means that a large percentage of patients present an anatomic variation. The importance of the presence of a variant hepatic artery in pancreatic surgery has been commented in several publications. An RHA that irrigates in the SMA has a close relationship with the head of the pancreas since its course is adjacent and occasionally passes through its parenchyma. The absence of collateral vascularization and the inadvertent sectioning of an RHA branch of the SMA during a pancreaticoduodenectomy (PD) can lead to ischemia and necrosis of the right liver lobe. Finally, once the gastroduodenal artery (GDA) is dissected, the RHA branch of the SMA becomes the main source of vascularization of the distal common bile duct.

Materials and methods: A total of 103 patients underwent da Vinci robotic pancreaticoduodenectomy (RPD) between January 2012 and July 2018 were analyzed by three surgeons. 27 patients underwent conventional RPD, 15 patients with pure RSPPD and 61 patients with RSPPD + 1 were performed. Besides, the PubMed database from 1950 to 2017 was systematically searched for comparative studies reporting management of the RHA during PD.

Results: A total of 103 patients were analyzed, of whom 17 (16.5%) had a RHA. In our study with infiltration by the tumor mass, or in those with an intrapancreatic pathway, the artery should be sacrificed with the PD surgical specimen and later reconstructed. An aberrant RHA (ARHA) that was satisfactorily resolved with end-to-end arterial reconstruction without the use of vascular stent. We used vascular micro-bulldog clamps between ARHA to dissect the gastroduodenal artery (GDA), while preserving as much of its length as possible.

Conclusion: In study, postoperative and oncological outcomes seemed unaffected by the RHA in PD. The robotic system combined with single port platforms are able to overcome the current limitations even vascular anastomosis in ARHA. The robotic PD is safe and feasible in appropriately selected patients.



M. de Pastena, A. Pulvirenti, L. Landoni, M. Fontana, C. Bassi, R. Salvia General and Pancreatic Surgery, AOUI Verona, VERONA, Italy

Background: Postoperative pancreatic fistula (POPF) is the primary contributor to morbidity after distal pancreatectomy (DP). To date, no techniques used for the transection and closure of the pancreatic stump showed a clear superiority over the others. This study aimed to compare the rate of POPF after pancreatic transection conducted with the reinforced stapler (RS) and ultrasonic dissector (UD) following DP.

Method: Consecutive patients underwent DP from 2014 to 2017 were retrospectively reviewed. We included DPs where pancreatic transection was performed by RS or UD and excluded DPs extended to the pancreas head. To overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for POPF.

Results: Overall, 200 patients met the inclusion criteria. The RS was employed in 108 patients and UD in 92 cases. After the one-to-one propensity matching, 92 patients were selected from each group. The matched RS and UD cohort have no differences in baselines characteristics except for the mini-invasive approach, that was more common in the UD group (34% vs. 51%, p = 0.025). Overall, 48 patients (26%) developed a POPF, 46 a grade B (25%) and 2 (1%) a grade C. In the RS group the rate of POPF was 12% (n = 11) and the UD group 38% (n = 35) with a p < 0.001.

Conclusion: The results of this study suggest that the use of RS for pancreatic transection, reduces the risk of postoperative pancreatic fistula. A randomized trial is needed to confirm these preliminary data.



C.M. Peng General Surgery, Da Vinci MIS Center/Chung Shan Medical University Hospital, TAICHUNG, Taiwan

Aim: This study compares clinical and cost outcomes of robot-assisted single port and open longitudinal pancreaticojejunostomy (RLPJ and OLPJ) for chronic pancreatitis. Single incision MIS needs more manual skills than conventional multiport operation. The advantage of better operation course is 3D vision and dedicate instrument. This paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for chronic pancreatitis.

Materials and methods: Clinical and cost data were retrospectively compared between open and RALPJ. We collected 21 patients since July, 2015 to September, 2018. The patient was supinely placed in reverse Trendelenburg position. The assistant surgeon was located between patient’s legs. Under general anesthesia a trans-umbilical 4.0 cm skin incision was made. A single incision advanced access platform with Lagis port, Glove Port® (Nelis, S. Korea) and Gelpoint combined with the da Vinci Si and Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) pure or plus one was performed. The three arms, No. 1, No. 2, and da Vinci scope, were in dwelled through the Glove Port®. Pneumoperitoneum of 12 mmHg was established through the port. A rigid 30-degree up scope was used during operation.

Results: Twenty-one patients underwent LPJ: 5 open and 16 RALPJ. No robot-assisted cases converted to open were noted. Patients undergoing RALPJ had less intraoperative blood loss, a shorter surgical length of stay, less postoperative pain and lower medication costs. Operation supply cost was higher in the RALPJ group. No obvious difference in hospitalization cost was found.

Conclusions: Versus the open approach, RALPJ performed for chronic pancreatitis shortens hospitalization, less postoperative pain and reduces medication costs; hospitalization costs are equivalent. A higher operative cost for RALPJ is mitigated by a shorter hospitalization and less pain control. Robot-assisted Puestow procedure using single port platform is feasible and safe method. The total procedures by da Vinci Robotic system are safe and easily performed in highly selected patients.

O085—HERNIA-ADHESIONS—Abdominal wall hernia


F. del Castillo Diez 1, L. García-Sancho Téllez2, C. Durán Escribano3, E. Alvarez Peña1, M. Heras Garceau1, J.A. Gonzalez Sanchez1, J. Díaz Dominguez1 1General Surgery, Hospital Universitario La Paz, MADRID, Spain; 2General Surgery, Hospital Universitario Infanta Sofia, MADRID, Spain; 3General Surgery, Hospìtal Quirón La Luz, MADRID, Spain

Aims: The concomitant presence of abdominal wall midline hernias and diastasis recti is frequent. Diastasis recti might be a risk factor not only for having but for recurrence of midline hernias. Most open surgical procedures not consider the treatment of both pathologies, nor laparoscopic most spread out approaches. The Author presents a novel endoscopic, extraperitoneal and retromuscular hernioplasty technique and its preliminary results.

Methods: A serie of 15 patients is presented. A CT abdominal wall study is performed preoperatively. They all presented abdominal wall midline hernias in presence of a > 3.5 cm concomitant diastasis recti. There were 8 females and 8 males. A totally endoscopic, extraperitoneal and retromuscular repair was performed, that included a midline anatomic restoration, tension-free hernia gap closure, omphaloplasty and skin treatment, if needed in every case. The tension-free massive-meshed hernioplasty included a bilateral totally endoscopic posterior components separation when needed. No drainages were used. All procedures included a bladder catheterization.

Results: All patient were dispatched within a period under 48 h. No reoperations were needed in postoperative period. Postoperative pain was measured by an EVA scale. 85% of the patients have no pain medication after 24–48 h dispatching from hospital. 25% of the patients have a skin suffusion or hematoma. A male patient presented a temporary abdominal asymmetry due to a unilateral posterior component added to his technique. The mean following-up is to 6 months (1–12 months). No recurrence was observed.

Conclusions: Preliminary results demonstrate this new approach to be a safe, feasible and a reproductible procedure. The ‘TERRA’ novel technique could provide of a new minimally invasive approach to abdominal wall midline hernias repair in the presence of a diastasis recti. Only time and new results can predict the spreading out of this ‘third way’.

O086—HERNIA-ADHESIONS—Abdominal wall hernia


S.A. Canton, S.D. Pianalto, C. Pasquali DiSCOG Department of Surgery, Oncology and Gastroenterology, University of Padua, PADOVA, Italy

Aims: We devised a sutureless technique (‘Slim-Mesh’, SM) to treat giant (GH 10–20 cm)/massive (MH = 20 cm without loss of domain) ventral hernia in order to reduce intra- and postoperative complications and to lower operative time.

Methods: Between September 2009 and October 2018, 27 patients with GH/MH were operated at Padua University-Hospital with the SM technique. Data on all patients were collected prospectively (67%) and retrospectively (33%).

Results: This study comprised 15 males and 12 females. Mean age was 62 years (range 33–82 years) and mean body mass index was 30. GH and MH were found intraoperatively in 22 and 5 cases respectively. Mean operative time for all hernias (GH/MH) was 122 min (range 70–240 min); 113 min for GH (range 70–155 min); and 169 min for MH (range 105–240 min). In 51.8% of cases, hernia operative measurement was larger than preoperative size, especially in cases of incisional hernias (64.2%). In 29.6% of cases, laparoscopy found additional abdominal wall defects previously undetected by physical examination and by US- and/or CT-scan. A composite mesh and a non-composite mesh (up to 30 cm in size) were used in 96.3% and 3.7% of cases respectively. The Ethicon SecureStrap?? Absorbable Fixation Device straps for SM fixation were employed in 77.8% of cases. Mean length of hospital stay was 2.8 days. Mean follow-up time was 33 months (range 1–109 months). In our study, there was one early (< 30 days) postoperative seroma (3.7%), plus one late, small (2 cm) symptomless recurrence, but neither needed reoperation.

Conclusion: The sutureless SM technique facilitates intra-abdominal introduction, as well as the handling and fixation of large/very large meshes. This new approach is safe and fast, even in cases of GH/MH repair.

O087—HERNIA-ADHESIONS—Abdominal wall hernia


M. Dudai, K. Ittah Gilboa Surgery, MERAV Medical Center, Hernia Excellence, TEL AVIV, Israel

Aims: Any Ventral Hernia (VH) combined with Rectus Muscle Separation (RMS) must be repaired along with repairing the RMS, otherwise there is a high risk for Hernia Recurrence. Open RMS repair is vast and traumatic surgery and Laparoscopy is not effective. At 2015 a new era of repairing Abdominal Wall Hernia by Assisted Endoscopy started with Wolfgang Reinhold’s MILOS procedure. These procedures are somewhat complexed and real reconstruction of the Linea Alba (LA) was limited, which done better by Ferdinand Koeckerling’s ELAR technique. We perfected the ELAR technique to be fully endoscopic with wide mesh fusing to the muscles immediately by Fibrin Glue: Extended Endoscopic Hernia & Linea Alba Reconstruction Glue (eEHLARglue), achieving a low traumatic MIS for VH and RMS with excellent surgical and cosmetic results.

Methods: Our eEHLARglue is a totally endoscopic based technique used since 2017. Penetrating with Optiview trocar and CO2 pressure to the Anterior Rectus Sheet (ARS) level is followed by an extensive endoscopic dissection of the sub-cutaneous fat tissue from the ARS. Three trocars are inserted at the supra-pubic line enabling the dissection up to the Xiphoid and costal margins laterally. Any Hernia sac is dissected, and the content reduced back to the abdominal cavity. Relaxing Incisions of the ARS are performed longitudinally in the lateral aspect. The LA is reconstructed by running two layers of non-absorbable sutures from Xiphoid to Pubis. A light Mesh 30X15 cm is applied over the repair and the mesh is fused immediately to the muscles by Fibrin Glue.

Results: 25 patients underwent the eEHLARglue with follow up of 24 months. All had significant RMS of 5–10 × 14–26 cm combined with primary or recurrent VH. Recovery was smooth with 1–3 days of simple analgesics and return to regular activity within 4–10 days. No one had recurrent VH, but two males had limited RMS and two early cases Seroma formation.

Conclusions: Our eEHLARglue enables endoscopic VH repair and LA reconstruction with extra-strength received by immediate mesh fusion to muscles with Fibrin glue. Thus, achieving low traumatic MIS, easy recovering and very effective results—a perfect solution for patients with VH combined with RMS.

O088—HERNIA-ADHESIONS—Abdominal wall hernia


K. Iles1, M. Portelli 1, T. Bezzina2 1Department of Surgery, Mater Dei Hospital, MSIDA, Malta; 2Department of Health Sciences, Mater Dei Hospital, MSIDA, Malta

Background: Minimally invasive surgery is gradually becoming the mainstay of surgical treatment. Two techniques have been developed in management of inguinal herniae—the Trans-abdominal pre-peritoneal (TAPP) and the Total extraperitoneal (TEP) repair.

Method: A literature search was carried out on PubMed, MEDLINE, EMBASE and Google Scholar, using MESH terms ‘Inguinal Hernia’, ‘Randomised Controlled Trials’ (RCT), ‘TEP’, ‘TAPP’, ‘Laparoscopy’. All RCTs published until December 2017, comparing TAPP and TEPP inguinal hernia repair were identified. Data was collected on post-operative pain, hospital stay, operative time and seroma formation.

Results: Twelve blinded prospective RCTs were used. When compared to TEP repair, TAPP repair has comparable Seroma formation rates (Chi2 = 7.94; (P = 0.02); CI − 4.31, 0.55; I2 = 75%) and Post-op pain at 24 h (Chi2 = 30.28; (P = 0.00001); CI − 0.31, 0.06; I2 = 87%). However, TEP repair is associated with a significantly shorter operative time (Chi2 = 502.95; (P = 0.00001);CI 0.24, 0.48; I2 = 98%), Post-op pain at 1 hour (Chi2 = 11.26; (P = 0.004); 0.05, 0.30; I2 = 82%) and shorter hospital stay (Chi2 = 455.14; (P = 0.00001); CI 0.72, 1.07; I2 = 99%).

Conclusion: TEP is significantly better than TAPP repair with regards to operative time, post-op pain at 1 h and hospital stay. There is no significant difference with regards to post-op pain at 24 h and seroma formation.

O089—HERNIA-ADHESIONS—Abdominal wall hernia


A. Andreou 1, J. Garcia-Alamino2, S. Hajibandeh3, S. Hajibandeh4, M. Weitzendorfer5, F.E. Muysoms6, F.A. Granderath7, G.E. Chalkiadakis8, K. Emmanuel9, M. Gioumidou10, S. Iliopoulou-Kosmadaki10, M. Mathioudaki10, K. Souliotis10, S. Antoniou11 1Department of Colorectal Surgery, York Teaching Hospital NHS Foundation Trust, YORK, United Kingdom; 2Nuffield Department of Primary Care Health Sciences, University of Oxford, OXFORD, United Kingdom; 3General Surgery Department, Salford Royal Foundation Trust, SALFORD, United Kingdom; 4General Surgery Department, North Manchester General Hospital, MANCHESTER, United Kingdom; 5Department of Surgery, Paracelsus Medical University, SALZBURG, Austria; 6Department of Surgery, Maria Middelares Hospital, GHENT, Belgium; 7Center for Minimally Invasive Surgery, Neuwerk Hospital, MÖNCHENGLADBACH, Germany; 8Department of General Surgery, University Hospital of Heraklion, HERAKLION, Greece; 9Department of General Surgery, Paracelsus Medical University, SALZBURG, Austria; 10School of Medicine, University of Crete, HERAKLION, Greece

Aims: Single-incision laparoscopic surgery (SILS) is a new technique that aims to minimize abdominal wall trauma and improve cosmesis. Concerns have been raised about the risk of trocar site hernia following SILS. This study aims to assess the risk of trocar site hernia following SILS compared to conventional laparoscopic surgery, and investigate whether current evidence is conclusive.

Methods: We performed a systematic search of MEDLINE, AMED, CINAHL, CENTRAL and OpenGrey. We considered randomized clinical trials comparing the risk of trocar-site hernia with SILS and conventional laparoscopic surgery. Pooled odds ratios with 95% confidence intervals were calculated using the Mantel-Haenszel method. Trial sequential analysis usingthe Land and DeMets methodwas performed to assess the possibility of type I error and compute the information size.

Results: Twenty-three articles reporting a total of 2471 patients were included. SILS was associated with higher odds of trocar-site hernia compared to conventional laparoscopic surgery (odds ratio 2.37, 95% confidence interval 1.25–4.50, p = 0.008). There was no evidence of between study heterogeneity or small study effects. The information size was calculated at 1687 patients and the Z-curve crossed the O’Brien-Fleming a—spending boundaries at 1137 patients, suggesting that the evidence of higher risk of trocar-site hernia with SILS compared to conventional laparoscopic surgery can be considered conclusive.

Conclusions: Single-incision laparoscopic procedures through the umbilicus are associated with a higher risk of trocar-site hernia compared to conventional laparoscopic surgery.

O090—HERNIA-ADHESIONS—Abdominal wall hernia


E. Kakiashvili 1, E. Brauner2, H. Gilshtain2 1General Surgery, Galilee Medical Center, KIRIAT MOZKIN, Israel; 2General Surgery, Rambam Medical Center, HAIFA, Israel

Aim: robotic techniques relevance in inguinal hernia surgery is being examined. The study presents comparison of perioperative outcome between different surgical approaches for inguinal hernia.

Methods: retrospective cohort of 137 patients that underwent inguinal hernia repair at Rambam Medical Center during 2014–2016. Patients data was collected based on demographic characteristics, BMI, operating room time (ORT), Visual Analog Scale for Pain (VAS), postoperative need of analgesic, length of hospitalization (LOH) and perioperative complications.

Results: study population included 97 patients that underwent open inguinal hernia repair [12 bilateral (12.4%); 85 unilateral (87.6%)], 16 laparoscopic [8 bilateral (50%); 8 unilateral (50%)] and 24 robotic repair [17 bilateral (70.8%); 7 unilateral (29.2%)].

Postoperative VAS level was significantly higher in open technique than in laparoscopic or robotic technique [median: 5.0 vs 2.0 vs 0; p < 0.001]. Need of analgesics (per day) after surgery was also higher in open technique than in laparoscopic or robotic technique [median: 3.0 vs 1.5 vs 1.0; p < 0.001).

Operative room time (ORT) was much longer in robotic technique than in laparoscopic and or open technique [median: 92.5 min vs 79.0 min vs 44 min; p < 0.001).

Length of hospitalization was similar in each group (median1.0 day).

There was no different in terms of postoperative complications between three groups.

Conclusions: robotic inguinal hernia repair is technically feasible and safe procedure. Operative room time for robotic cases is significantly longer than laparoscopic and open techniques and there is substantial additional supply cost. There is clear benefit of robotic and laparoscopic techniques, comparing to open approach, in terms of patients postoperative recovery. Technical advantages of robotic technique and short learning curve may cause the more wide popularization of minimal invasive approach of the surgical management inguinal hernia.

O091—HERNIA-ADHESIONS—Abdominal wall hernia


A. Yehya Pediatric Surgery Department, Al-Azhar University Hospitals, CAIRO, Egypt

Background: Primary hyperhidrosis (PH) is a neurological condition characterized by excessive sweating most often of the face, palms or axillae . Palmar hyperhidrosis is treated through sympathetic chain clipping or transection .We aiming to compare the efficacy and results obtained with both techniques.

Patients and Methods: Sixty Four patients underwent of 128 sympathetic procedures from March 2013 to February 2017. The patients were categorized into two groups: Right sided transection sympathectomy and left sided clipping . Patients were evaluated to compare the rates of success, satisfaction, compensatory sweating and recurrence either with transection or clipping of the T3 andT4 ganglion .Mean follow up was 15 + _7 months.

Results: Sixty Four patients 24 males and 40 females undergoing electro-coagulation sympathectomy on the right side and clipping on the left side. With mean age was 15 years (range 13 to 18 years). All patients had balanced demographic data . No statistical difference between the two groups according rate of success. Compensatory sweating was observed in 28 patients (43.75%) overall with 4 cases of severe unsatisfied compensatory sweating. Recurrence was reported in one case with transection and 2 cases in clipping. Satisfaction was occurred in 63 cases in transection group and 61 cases in clipping group .Pnumothorax was occurred in 2 cases in transection group compared to one case in clipping. No gustatory sweating and over dryness were reported in both groups.

Conclusion: Both thoracoscopic sympathetic transection and clipping of T3T4 ganglion are safe and effective procedure in palmar hyperhidosis treatment. with no differences regarding recurrence rate,satisfaction and incidence compensatory sweating.

Keywords: thoracoscopic sympathectomy,palmar hyperhidrosis, clipping, compensatory hyperhidrosis.

O092—HERNIA-ADHESIONS—Abdominal wall hernia


S. Jamel 1, S. Huf2, K. Tukanova1, S. Markar1, S.M. Hakky1, S. Purkayastha1 1Department of Cancer and Surgery, Imperial College London, LONDON, United Kingdom; 2Imperial College London, LONDON, United Kingdom

Introduction: Primary ventral hernias and ventral incisional hernias pose a challenge for surgeons throughout the ages. Even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardized method that adequately decreases postoperative complications. Hybrid hernia repair is a surgical repair, which has not been adopted widely. It combines both a laparoscopic and open component allowing sac excision, primary defect repair as well as laparoscopic mesh insertion.

Aims: To evaluate the short-term and long-term outcomes of hernia recurrence for patients undergoing hybrid ventral repair (HVR) for the treatment of primary and incisional ventral hernias.

Methods: Between October- 2012 and June- 2013, hybrid VHR was performed in 24-patients at St Mary’s Hospital, Imperial College London. The medical records of these patients were reviewed retrospectively for demographics, comorbidities, prior surgeries, body mass index (BMI), hernial defects, hybrid technique used; mesh selection, operative time, complications and recurrences over a 5-year follow-up.

Results: Twenty-four patients who underwent hybrid VHR were included with surgery performed by two surgeons. The mean age is 48-years with a mean BMI of 33.1 kg/m2. 88% had incisional hernias and 12% had primary hernias. The number of hernia defects ranged from 1 to 4, with the average mesh size used was 15x17 cm. Extensive adhesionolysis was performed in 58% of patients.

30-day postoperative complications; 2 patients developed post-operative seroma, paralytic ileus in 1, pain control in 1 and urinary retention in 1 patient. There were no conversions to open procedures.

The mean length of hospital stay was 2-days. None of the patients developed chronic pain and only one recurrence over the 5-year follow-up period.

Conclusions: The hybrid technique for VHR is safe and feasible, and has important benefits over an open or purely laparoscopic approach, including a low rate of seroma formation, chronic pain and five-year hernia recurrence. Future investigation may include randomized controlled trials, to fully evaluate the benefits of hybrid VHR, with careful assessment of patient-centred end-points including quality of life and postoperative pain.

O093—HERNIA-ADHESIONS—Abdominal wall hernia


K. Haxhirexha 1, F. Dika-Haxhirexha2, N. Baftiu3, T. Emini1, B. Fejzuli4, A. Ademi1 1Surgery, Medical Faculty—University of Tetove, TETOVE, Macedonia; 2General medicine, Medical Faculty—University of Tetove, TETOVE, Macedonia; 3Anestesiology, Medical Faculty—University of Tetove, TETOVE, Macedonia; 4Surgery, Clinical Hospital—Tetove, TETOVE, Macedonia

Laparoscopic cholecystectomy is widely used operative technique and it’s characterized with less postoperative hospitalization and side effects.

Duration of the hospitalization after laparoscopic surgery depends on several factors of which pain and physical weakness are the most important. Dexamethasone is well known; not only for its anti inflammatory effects but at the same time for analgesic and antiemetic effects, although the mechanism of this effects are not clarified yet.

Objectives: The aim of our study is the evaluation of analgesic effect of dexamethasone on reducing postoperative pain after laparoscopic surgery.

Patients and Methods: In this study, 200 patients aged 25 -74 years old undergoing laparoscopic surgery, were classified into two groups, 100 patients in each group. The first group were treated with a intravenous injection of 8 mg dexamethasone preoperatively and another dose the next day after operation. The second group received a intravenous injection of normal saline. We evaluated the dose of consumed analgesics and antiemetic’s drug during the first 24 h in both groups.

Results: According to our experience results the total dose of tramadol in a postoperative period in dexamethasone receiving group was smaller than in normal saline group. Measure of postoperative pain was assessed using the paper-based VAS scale. Our result shows that the intensity of post operative pain in a period during first 36 h, after surgery in a group of patients treated with dexamethasone was lower compared with the group of patients treated with normal saline. Nausea and vomiting during the first 36 h was significantly lower in the dexamethasone group than in the normal saline group.

Conclusion: Dexamethasone decreases postoperative pain, nausea and vomiting in patients after laparoscopic surgery as well as the need for analgesics.

Key words: dexamethasone, laparoscopic surgery, pain

O094—HERNIA-ADHESIONS—Abdominal wall hernia


J. Gomez Menchero 1, A. Gila Bohorquez1, E. Licardie Bolaños2, J.A. Bellido Luque3, J.M. Suarez Grau1, M. Sanchez Ramirez3, J. Garcia Moreno1, J. Landra1, I. Alarcon del Agua4, S. Morales Conde4 1Surgery, Hospital de Riotinto, MINAS DE RIOTINTO, Spain; 2Surgery, Hospital Quiron Sagrado Corazon, SEVILLA, Spain; 3Surgery, Hospital Virgen Macarena, SEVILLA, Spain; 4Surgery, Hospital Virgen del Rocio Sevilla, SEVILLA, Spain

Aims: Closing the Defect (CD) during Laparoscopic Ventral Hernia Repair (LVHR) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional LVHR. But tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a Component Separation (CS) for restoring the midline in medium-large defects.We have developed a new technique for restoring the midline in medium ventral hernias (LIRA Technique) and weanalyzed our results in terms of pain and recurrence compared to our Conventional CD series (CCD).

Methods: We conducted a prospective controlled study of LVHR with CCD from January 2014 to December 2016 and a prospective controlled study performing LIRA technique from January 2015 to January 2017. We analyzed and compared both techniques in medium size defects (4–8 cms) in terms of postoperative pain (1, 7 days, 1, 3 months and 1 year) using a Visual Analogue Scale (VAS), Bulging (return to prior distance among rectus muscles with the mesh in the sac in CT that didn’t need surgical treatment)and recurrence (by physical examination and Tomography).

Results: CCD was performed in 42 patients (mean age was 58.10 ± 13.15 years old and mean BMI was 33.11 ± 6.61 kg/m2) and LIRA technique in 12 patients (Mean age was 56.5 ± 10.5 years old and mean BMI was 30.12 ± 5.30 kg/m2). The mean average Follow-up in both series was 1 year. Mean average VAS in CCD was 5.35 ± 2.49 (1 day), 2.01 ± 2.13 (7 days) 0.62 ± 1.45 (1 month) 0.10 ± 0.43 (3 months) and 0 at 1 year. In LIRA series VAS was 3.9 ± (24 h) 1.08 ± 1.78 (7 days), 0.08 ± 0.28 (1 month), 0 (3 months) and 0 (1 year). There are 6 cases of Bulging in CCD series and 1 recurrence. Bulging and recurrence were absent in LIRA series.

Conclusions: LIRA technique might be a safe procedure in medium size defects for restoring the midline in LVHR, and could be related to a lower pain rate compared to CCD with no recurrence or bulging.

O095—HERNIA-ADHESIONS—Abdominal wall hernia


R. Shalaby 1, M. Abd-Alrazek1, A. al-Saied2, S. Mohamad1, A. Seddek1 1Pediatric Surgery, Al-Azhar University Hospitals, CAIRO, Egypt; 2Pediatric Surgery, Mansour University, MANSOURA, Egypt

Background: The desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endo-surgery [SIPES] and needlescopic surgery. Intracorporeal suturing and knot tying during SIPES remains challenging. The aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. It is an imitation of the principles of sewing machine.

Methods: The first author discussed the idea of the technique with the co-authors and a demonstration was done on a Silicon Pad before application of the technique on children with congenital inguinal hernia [CIH] for peritoneum closure after needlescopic disconnection of the hernia sac. The main outcome measurements were; feasibility of the technique, knot quality, suture placement accuracy, performance and suturing time and recurrence rate.

Results: The sutures were snugly applied to the ridges of Silicon Pad with good approximation and the knot was firmly tightened in all experiments. After applying and mastering the technique on a Silicon Pad, we shifted to use it on 373 children with 491 hernia defect. All operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. The time required for suturing of the peritoneum around internal inguinal ring [IIR] and knot tying, decreased considerably from 5 min 27 s in the first operation to less than 3 min after the fifth operation and stabilized at approximately 2 minute 30 s. No major intraoperative complication and no recurrence.

Conclusion: The closure of the peritoneum around the IIR using needles mimicking what is happening in sewing machine suturing is feasible, safe and effective line of treatment of children with CIH. The cosmetic results are outstanding without any recurrence.

O096—HERNIA-ADHESIONS—Abdominal wall hernia


V. Ferri, B. Ielpo, E. Vicente, Y. Quijano, D. Hipolito, E. Diaz, I. Fabra, L. Malave, R. Isernia, E. Pinna, R. Caruso General Surgery, Sanchinarro University Hospital, MADRID, Spain

Background and Aims: In the last decade there has been an increased interest in the laparoscopic repair approach of inguinal hernia showing benefits. We expect that even more benefits may exist for bilitateral inguinal hernias

However, in the scientific literature, benefits of laparoscopic versus open approach for bilateral inguinal hernia repair are still unknown.

The aim of this study is to compare the open Lichtenstein repair (OLR) and laparoscopic trans-abdominal preperitoneal (TAPP) repair.

Study design: This study was conducted at Sanchinarro University Hospital between March 2013 and May 2017.

Patients who presented with a primary, reducible bilateral inguinal hernia were included as patients which reach a minimum of one year of follow up. Outcome parameters included hospital stay, operation time, postoperative complications, immediate postoperative and chronic pain, recurrence. Quality of life according to the standardized SF36 questionnaire was recorded. The outcome parameters included surgical and post-operative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER).

The primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups.

Results: A total of 148 patients were enrolled (70 of them underwent TAPP and 78 OLR). Drop out occurred in 5 cases (2 of TAPP and 3 of OLR group).

Patient characteristics were statistically similar between the 2 groups. TAPP procedure had less early post-operative pain (p = 0.037), a shorter length of stay (p = 0.031) and less postoperative complications (p = 0.002) when compared with the OLR approach. A slightly higher recurrence rate in the TAPP group was found. Additionally, there is a trend towards a higher postoperative quality of life and less chronic pain in the TAPP group.

Conclusions: TAPP procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications.

O097—HERNIA-ADHESIONS—Abdominal wall hernia


E. Schembari 1, E. Mattone1, R. Lombardo2, M. Sofia2, V. Randazzo2, G. la Greca1, D. Russello1 1Cannizzaro Hospital, University of Catania, CATANIA, Italy; 2Cannizzaro Hospital, CATANIA, Italy

Aim: The purpose of this study was to evaluate the long-term results in terms of safety and efficacy of a new technique to repair incisional ventral hernias with a self-gripping mesh, after a mean follow-up period of 15 months.

Methods: A retrospective, single-centre study was performed from June 2016 to June 2018. All patients undergoing elective incisional ventral hernia repair were included. Hernias were diagnosed based on clinical examination at the outpatient clinic. In case of doubtful diagnosis, CT-scan was used to confirm the diagnosis. The component separation technique and, when needed, TAR were performed. The self-gripping mesh was placed in sublay position (overlap 5 cm) with the self-gripping surface face down. In all cases drainage tubes were placed in retromuscular and supraaponeurotic position. The following characteristics were collected: age, sex, Body Mass Index (BMI), smoking, comorbidities, number of previous surgical operations, defect size (EHS classification), mesh size, postoperative complications, duration of follow-up. All patients were interviewed by telephone every six months. When patients complained recurrence or other symptoms, visits were organized and when there was the doubt of recurrence a CT-scan was performed.

Results: A total of 40 patients were included in this study, 21 males, mean age was 59 years. 83% of patients had BMI > 25, smokers and diabetics were respectively 28% and 9%. The mean defect size was 115 cm2. Component separation technique was associated with TAR in 6 patients. In 11 cases the size of mesh was 20 × 15 cm, while in 7 patients the size of mesh was 30 × 15 cm and in 11 cases this was 15 × 15 cm. In the other patients the mesh sizes were tailored to defect dimensions. Subcutaneous seromas occurred in 7 patients, they were treated conservatively in 5 cases and with percutaneous punction in 2 cases. Long-term follow-up demonstrated recurrences in one case, while in another one CT-scan revealed a bulging. No cases of mesh infection, pain or sensation of mesh.

Conclusions: This study with a mean follow-up period of 15 months demonstrated that the use of self-gripping mesh in sublay position is safe and effective to treat incisional ventral hernias.



M. Ortenzi 1, G.I. Lezoche1, G.I. Biondini1, A.N. Balla3, A.M. Paganini3, M.A. Guerrieri1 1Clinica Chirurgica, Università Politecnica delle Marche, ANCONA, Italy; 3Department of General Surgery and Surgical Specialties, Paride Stefanini, Sapienza University of Rome, ROMA, Italy

Aim: Morgagni hernias present technical challenges. The laparoscopic approach was described at first in 1992, however, as they are uncommon in adult life and, little data exist on the optimal method of surgical management. This study purpose was to analyse a method for laparoscopic repair of Morgagni giant hernias using laparoscopic primary closure.

Methods: This case series describes a method of laparoscopic Morgagni hernia repair using primary closure. In all patients a laparoscopic transabdominal approach was used. The content of the hernia was reduced into the abdomen and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. Clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. Demographic data as age, gender and BMI were collected. Operative data (operative time, rate of conversion, blood loss) and post-operative data (short and long term complications, length of hospital stay, need of readmission and reoperation) were recorded.

Results: Retrospectively collected data about 9 patients were analysed. There were 1 (11.1%) male and 8 (88.8%) females. The median BMI was 29.14 ± 5.2 Kg/m2. Median operative time was 80 ± 25 min. There were no intraoperative complications nor conversion to open surgery. Patients began a fluid diet on the first post-operative day and were discharged after a median hospital stay of 3 ± 1.87 days. In a median follow up of 36 months we did not observe any recurrences.

Conclusions: Transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for repair of Morgagni hernia. In our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs.



C. Tellez Marques, E. Sebastian Valverde, E. Membrilla Fernandez, L. Grande Posa, I. Poves Prim General surgery, Parc de Salut Mar-Hospital del Mar, BARCELONA, Spain

Aims: The laparoscopic approach in the acute adhesive small bowel obstruction and internal hernias (ASBO) has shown superior to laparotomy in terms of morbidity and hospital stay. Especially, in patients who present simple adhesions or internal hernias. According to this, the aim of the study is to determine those preoperative factors associated with simple adhesions and internal hernias, and consequently, improve the success of the laparoscopic approach in ASBO

Methods: A retrospective study of patients who underwent urgent surgery for ASBO was conducted from January 2007 to May 2016. We compare preoperative variables between single adhesions and internal hernias vs complex adhesions. A p value < 0.05 was considered statistically significant.

Results: We analysed 262 patients who underwent surgery for ASBO, 78 (30%) by laparoscopy and 184 (70%) by laparotomy. Conversion rate in laparoscopy was 38.5%. 49.2% of patients presented a single adhesion or internal hernia; and 50.8% were considered complex adhesions. Sex and age did not correlate with the type of adhesions. Previous surgery (p < 0.001), number of previous surgeries (p < 0.001), ASA (p < 0.001) and previous abdominal wall mesh (p = 0.002) were significantly associated with complex adhesions. Laparoscopy as the only surgical history was significantly associated with simple adhesions (p = 0.033). Only appendectomy (p = 0.139) or supramesocolic (p = 0.076) previous surgeries tended to present single adhesions but it did not reach statistical significance. The need for intestinal resection was not related to the type of adhesions (p = 0.743). There was a significant correlation between the findings in the CT (computed tomography) and the type of adhesion found (p = 0.001). Signs of ischaemia on CT were related to the need for intestinal resection (p < 0.001). In the multivariate analysis, the number of previous surgeries, ASA and CT scan findings were identified as independent factors related to the type of adhesion.

Conclusions: According to our study, a lower number of previous surgeries, ASA I-II and internal hernia in the CT scan are associated with single adhesions and internal hernias. Patient selection is a key factor for the success of laparoscopic approach in ASBO.

O100—HERNIA-ADHESIONS—Emergency surgery


S.R. Markar1, K. Tukanova 2, A. Vidal-Diez2, G.B. Hanna2 1Surgery & Cancer, Imperial College London, LONDON, United Kingdom; 2Surgery & Cancer, St-Mary’s Hospital, Imperial College London, LONDON, United Kingdom

Aims: There aims of this study were:

(i) To compare England with the United States in the utilisation of minimal access surgery (MAS) and in-hospital mortality from four common abdominal surgical emergencies (appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel perforation and peptic ulcer perforation).

(ii) Within England to evaluate the influence of MAS upon in-hospital and long-term mortality.

Methods: Between 2006 and 2012, the rate of MAS and in-hospital mortality for four abdominal surgical emergencies were compared between the United States and England. Univariate and multivariate analyses were performed to adjust for underlying differences in baseline patient demographics.

Results: 132,364 admissions in England for four abdominal surgical emergencies were compared to an estimated 1,811,136 admissions in the United States.

After adjustment for patient demographics, MAS was used less commonly England for three conditions; appendicitis (odds ratio (OR) 0.30, 95% CI 0.30–0.31), abdominal hernia (OR 0.18, 95% CI 0.17–0.19) and small or large bowel perforation (OR 0.48, 95% CI 0.46–0.51).

In-hospital mortality in multivariate analysis, was increased in England compared to the United States for three conditions; abdominal hernia (OR 1.91, 95% CI 1.81–2.01), small or large bowel perforation (OR 2.33, 95% CI 2.25–2.42) and peptic ulcer perforation (OR 2.02, 95% CI 1.91–2.14).

In England, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for three conditions; abdominal hernia (OR 1.80, 95% CI 1.26–2.71), small or large bowel perforation (OR 1.59, 95% CI 1.37–1.87) and peptic ulcer perforation (OR 2.31, 95% CI 1.91–2.82). Similarly open surgery was associated with increased long-term mortality for three conditions; abdominal hernia (HR 1.32, 95% CI 1.15–1.52), small or large bowel perforation (HR 1.30, 95% CI 1.18–1.43) and peptic ulcer perforation (HR 1.69, 95% CI 1.50–1.89).

Conclusions: Minimal access surgery was used less commonly and in-hospital mortality was increased in England compared to the United States for common abdominal surgical conditions. Given the benefits of MAS shown in this large study, strategies to enhance adoption of MAS in emergency conditions in England need to be optimised and include appropriate patient selection and improved surgeon MAS training and experience.

O102—HERNIA-ADHESIONS—Inguinal hernia


S.A. Antoniou 1, F. de Haes1, S. Hajibandeh2, S. Hajibandeh3, F.E. Muysoms4, M. López-Cano5, J. Garcia-Alamino6, N.J. Smart1 1Surgical Service, Royal Devon & Exeter NHS Foundation Trust, EXETER, United Kingdom; 2General Surgery Department, Salford Royal Foundation Trust, SALFORD, United Kingdom; 3General Surgery Department, North Manchester General Hospital, MANCHESTER, United Kingdom; 4Department of Surgery, Maria Middelares Hospital, GHENT, Belgium; 5Abdominal Wall Surgery Unit, Department of General Surger, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, BARCELONA, Spain; 6Nuffield Department of Primary Care Health Sciences, University of Oxford, OXFORD, United Kingdom

Aims: Self-adhering meshes have been launched as material potentially reducing pain and surgery time. Meta-analyses of randomized trials (RCTs) have suggested no significant effect in terms of postoperative pain in open inguinal hernia repair. Aim of this study was to perform an update meta-analysis to consolidate the non superiority hypothesis of self-adhering mesh over traditional mesh and to investigate whether evidence is conclusive through trial sequential analysis.

Methods: The databases of Medline, Embase, CENTRAL and OpenGrey were interrogated to identify relevant RCTs. Incidence of pain and quantitative pain assessment through the Visual Analogue Scale (VAS) score were primary outcome measures. Duration of surgery was secondary outcome. The Mantel-Haenszel approach was used to synthesize data and sensitivity analyses included calculation of the Peto odds ratio, risk difference and random effects meta-analysis. The Lands & DeMets method was used for trial sequential analysis with a = 0.05, ß = 0.2 and O’Brien-Fleming a-spending boundaries. Relative risk reduction was calculated from low risk of bias studies. The analysis conformed to PRISMA standards.

Results: Thirteen RCTs with low to moderate risk of bias were identified. There was no difference in the incidence of pain at 3–12 months (risk ratio, RR 1.05, 95% confidence interval, CI 0.75–1.49), 2 years (RR 1.16, 95% CI 0.43–3.12), and 3–4 years (RR 0.93, 95% CI 0.45–1.93). VAS scores were also similar across follow up intervals. No difference in hematoma/seroma, wound infection, hospital stay, reoperation or recurrence was seen. Self-adhering mesh was associated with a mean operative time difference of − 7 min (95% CI − 10 to − 4). Trial sequential analyses consolidates non superiority in terms of long-term postoperative pain, the z-curve having passed the no effect boundary well beyond the information size.

Conclusion: Self-adhering mesh is not effective in reducing short-term and long-term postoperative pain after open hernia repair. This evidence is definitive and no further trials defining this endpoint are required. Reduction in operative time is negligible and the additional cost does not justify the routine use of self-adhering mesh in this context.

Registration: CRD42018069266

O103—HERNIA-ADHESIONS—Inguinal hernia


F. Mongelli 1, A. Ferrario di Tor Vajana1, M. Fitzgerald1, S. Cafarotti1, M. Lucchelli2, F. Proietti1, M. di Giuseppe1, D. la Regina1 1Surgery, Ospedale Regionale di Bellinzona e Valli, BELLINZONA, Switzerland; 2Medical Controlling, Ospedale Regionale di Bellinzona e Valli, BELLINZONA, Switzerland

Background: In the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related-group (DRG) era. Factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. The aim of this study is to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery.

Methods: This retrospective study analysed the 1-year experience in inguinal hernia repair in patients undergoing open Lichtenstein (OL), laparoscopic totally extraperitoneal unilateral (UTEP) or bilateral (BTEP) hernia repair. Demographics, results, costs and DRG-based reimbursements were recorded and analysed.

Results: During the study period, 39 patients underwent OL, 82 patients UTEP and 16 patients BTEP. The average total cost amounted to 4126 EUR in OL, 5134 EUR in UTEP and 7082 EUR in BTEP groups (p < 0.001*). The hospital reimbursement amounted to 5486 EUR, 5252 EUR and 6555 EUR in the OL, UTEP and BTEP groups respectively (p < 0.001*). Finally, the mean hospital earnings were 1360 EUR, 118 EUR and − 527 EUR for each patient in OL, UTEP and BTEP respectively (p < 0.001*).

Conclusions: In-hospital costs were higher in UTEP and BTEP as compared to OL. The DRG-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in OL group only, and led an overall financial loss in the BTEP group. Surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view.

O105—HERNIA-ADHESIONS—Inguinal hernia


F.M. Sanchez Margallo 1, F. Marinaro2, R. Blazquez Duran2, M. Veloso Brun3, J.G. Casado2 1Scientific Direction, Minimally Invasive Surgery Centre, CÁCERES, Spain; 2Stem Cell Laboratory, Minimally Invasive Surgery Centre, CÁCERES, Spain; 3Surgery, Universidade Federal de Santa Maria, SANTA MARIA, Brazil

Aims: Umbilical hernias are common anatomical defects in swine which become a suitable model for surgical training and research in the field of surgical meshes. The aim of this study was to develop a surgical protocol for a successful laparoscopic implantation of stem cell-coated surgical meshes.

Methods: 9 Large White pigs, weighing 25–68 kg and with congenital abdominal hernia were anesthetized for the surgical procedures. Non absorbable polypropylene surgical meshes were coated with fibrin glue (FG) (control group) or with FG admixed with porcine bone marrow-derived mesenchymal stem cells (FG/BM-MSCs). Approximation of hernia’s borders was performed by intracorporeal suture. The meshes were carefully rolled inside the trocar for laparoscopic implantation. The surgical implantation was performed by laparoscopy using helicoidal staples. Laparoscopic inspections and biopsies of the tissue surrounding the mesh were performed at 7, and 30 days post-implantation. At day 30, the animals were euthanized and macroscopically evaluated. Ultrasonography was used at day 0, 7, and 30 to evaluate the size of the hernia. The biopsies were then processed for the histological analysis.

Results: Ultrasonography demonstrated that the mean size of umbilical hernias before mesh implantation was 2.49 ± 0.99 cm. A decrease in hernia mean size was observed at day 7 and 30. The laparoscopic procedures allowed a successful mesh implantation in all animals. In most of cases, the implantation site did not show excessive inflammation or tissue adhesions. But one animal showed hernia maintenance. One animal had peritoneal and implant-site infection. Foreign body reaction was noted in the histological analysis, although no significant difference was found between the control, and BM-MSC group.

Conclusions: The anatomical similarities between humans and pigs in umbilical hernias make this animal model useful to: I) improve minimally invasive surgical procedures for hernia treatment; II) evaluate new surgical meshes, and III) introducing stem cell therapy to hernia surgical repair. The laparoscopic approach is efficient and safe for the implantation of stem cell-coated meshes. Gene and protein expression analysis are required to evaluate the molecular changes between the conventional and the stem cell surgical approach.

O106—HERNIA-ADHESIONS—Inguinal hernia


M. Tomala Klinik fuer Chirurgie, Schoen Klinik Neustadt, NEUSTADT IN HOLSTEIN, Germany

Background: The recurrence rates and the complication rates for groin hernia repair have been heterogeneous reported in the literature. Most of all the recurrence rates vary a wide range from 0.5 to 15%. The aim of the study was to report recurrence rates, complication rates and patient satisfaction from 1120 single-center transabdominal pre-peritoneal inguinal hernia surgeries (TAPP) performed at the Schoen Klinik Neustadt between 2005 and 2014.

Methods: A follow-up questionnaire was sent out to all by TAPP operated patients in 2016 and the electronic medical files were investigated.

Results: The response rate to the follow-up questionnaire was 60.5%. Patients reported a recurrence rate of 4.4% (95% confidence intervall (CI) 3.10%—6.30%). If patients had at least 5 years of follow-up, the recurrence rate was 5.23%, thus approximately 1.91 times higher when compared with patients with a follow-up between one and 5 years. In 9.86% of all surgeries, recurrence were operated. If patients had a recurrence at surgery, their odds for another recurrence was 3.30 times increased (p = 0.01). Patients with a recurrence had a higher body mass index (median 1.61 kg/m2). In 52.8% of patients, a medial inguinal hernia was recurrent, while lateral inguinal hernias were non-recurrent in 47.8% of operated patients. The risk of the complication (hematoma, seroma, wound infection) after TAPP was 4.80%, and the odds for a recurrence was 3.36 times higher in case of complication (p = 0.001). The general satisfaction of the patients with the results of operation was 81.65% in the group of satisfied and very satisfied patients, and 13.76% in the group of dissatisfied and very dissatisfied patients. Regarding the patient satisfaction there was a big discrepancy between a patient group with recurrence, complication and current pain at the operated groin when compared with the group without recurrence, complication and current pain.

Conclusions: In accordance to the literature, there was a discrepancy between the proportion of by TAPP operated recurrences and the recurrence rate at follow-up. It may be explained by differences in follow-up times and the exclusion of hospitals with lower number of operated patients in the general reporting of recurrences.

O107—HERNIA-ADHESIONS—Inguinal hernia


M. Dudai, K. Ittah Gilboa Surgery, MERAV Medical Center, Hernia Excellence, TEL AVIV, Israel

Aims: The pathologies of Sportsman Hernia (SH) are found in the Posterior Wall (PW), Conjoint Tendon and Inguinal Ligament (IL). As a consequence, high pressure is created in the Inguinal Canal (IC), on the Genital and Femoral branches of the Genitofemoral Nerve and the Lateral Cutaneous Nerves of thigh (GFLCN), causing entrapment during Sport Activities (SA). The aim of the SH surgical repair is to release those pressure who caused entrapments and then reinforce the PW. We are presenting a study that demonstrating the SH Thigh Nerves Entrapment (TNE) and its release by the TEP Inguinal Ligament Release & Reinforce Technique (IL-RRT).

Methods: Since 1986 we are using our TEP IL-RRT for repairing SH; combining Pressure Release with PW Reinforcing. A vast release of inflammatory adhesions on the Pubic bone and PW is performed, followed by dividing the IL at the level of the internal ring releasing the pressure from the GFLCN below it, which causes the entrapment. To complete the procedure, we are reinforcing the PW with wide light PPP mesh. The IL-RRT is followed by the Athletic Muscles Rehabilitation Program. On 2017 we started a study in order to demonstrate the TNE and its release by the TEP IL-RRT. Any SH candidate for TEP IL-RRT was tested for the presence of hypersensitivity or hyposensitivity according to his skin Thighs Dermatomes. Postoperatively he was re-tested, and findings were compared to the preoperative records.

Results: 90% of the preoperative SH candidates clinically tested, demonstrated positive finding for TNE. While in the postoperative checkup, positive findings for TNE persisted in less than 2% of the patients.

Conclusions: The injured IL is a major factor of pressure created in the IC and entrapping the GFLCN below it. Dividing the IL in addition to PW reinforcement, add a great advantage for relieving pain during SA. Positive changes demonstrated in TNE clinical examination following the TEP IL-RRT, prove both the pathophysiology of TNE in SH and the efficiency of the TEP IL-RRT to loosen it. That, in addition to excellent results of less than 0.5% persistence of the pain after returning to SA.



E. Licardie 1, T. Yang2, I. Alarcón2, V. Camacho2, M. Sánchez2, F. López2, M. Socas2, A. Barranco2, J. Padillo2, S. Morales-Conde2 1Sevilla, Hospital Quirónsalud Sagrado Corazón, SEVILLA, Spain; 2Unit of innovation in Minimally Invasive Surgery and Unit of General Surgery, University Hospital Virgen del Rocío, SEVILLA, Spain

Aims: Fluorescence angiography with indocyanine green (ICG) is used as a marker in the assessment of tissue perfusion, being more frequently used in colorectal procedures. This technology has shown to be a good technique to reduce complications related to vascular supply to the anastomosis. In esophagogastric procedures blood supply to the gastric pouch, jejunum and esophagus could be evaluated by ICG fluorescence imaging. It could be also used in bariatric surgery to evaluated the anastomoses, during Gastric Bypass, and blood supply to the gastroesophageal junction and the angle of His during Sleeve gastrectomy.

Methods: We have collected data during 8 gastric resection due to adenocarcinoma and 53 bariatric procedures that were performed by the same surgeon, using ICG fluorescence to evaluate blood supply. The ICG was infused before performing the anastomosis in order to evaluate the need to change the transaction line (TL). We analyzed those cases in which the TL was changed and the number of leaks in those cases that we changed this line.

Results: All the 61 cases were performed by laparoscopic approach: 5 Subtotal Gastrectomy (SG), 3 Total Gastrectomy (TG), 26 Gastric Sleeve (GS) and 27 Gastric Bypass. There were no changes regarding the TL before performing the anastomosis in any of the four types of procedures (SG, TG, GS, GB). In the analyzed data there is 1 anastomotic leak in one SG procedure (1.6%).

Conclusions: ICG fluorescence angiography could be helpful in assessing blood supply during gastrointestinal anastomosis, although we have not find an influence in the results during bariatric and gastric procedures. However, we do not have the sufficient evidence to determine the value of this technology in this entities, being needed more volume and data to improve the significance of the results.

O109—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


M. Barberio 1, F. Longo1, F. Fiorillo1, B. Seeliger1, P. Mascagni1, E. Seyller1, V. Agnus1, J. Marescaux2, M. Diana1 1Research Department, IHU, STRASBOURG, France; 3Research Department, IRCAD, STRASBOURG, France

Aims: Hyperspectral Imaging (HSI) combines a spectrometer with a camera to analyze the tissues’ optical properties in a broad wavelength range, without the need for a contrast agent. It provides extensive real-time information about tissue physiology, including oxygen saturation (StO2). Fluorescence-based Enhanced Reality (FLER) is a software solution providing a dynamic, quantitative analysis of the signal evolution of a systemically administered fluorophore, during fluorescence angiography (FA). The aim of this study was to compare the performance of HSI and FLER to assess bowel perfusion, in a porcine, non-survival model of bowel ischemia.

Methods: In 6 pigs, an ischemic small bowel segment was created and imaged after 1 hour of ischemia. The imaging modalities were applied sequentially to the same area.HSI was performed first, to acquire the StO2 spectra, by means of the TIVITA™ system (Diaspective Vision, Pepelow, Germany), which provides a spectral range of 500–1000 nm and a 5 nm resolution. Subsequently, FA was performed using a NIR-capable laparoscopic camera (D-Light P, Karl Storz, Germany), after intravenous injection of 0.2 mg/kg of Indocyanine Green (ICG; Infracyanine, Serb, Paris, France). The fluorescence flow was recorded during 40 s, then the slope of the fluorescence flow was analyzed using a proprietary software to obtain a virtual perfusion cartography. The virtual cartography was overlaid onto real-time images to obtain the enhanced reality effect. Ten adjacent regions of interest (ROIs) were selected from HSI datasets and were superimposed to FLER-generated cartographies using a custom plug-in software function, allowing for a quantitative comparison of both imaging modalities. HSI was repeated after ICG injection.

Results: The r2 correlation coefficient between HSI-StO2 and the FLER slope was 0.79. At control HSI after ICG injection, the correlation coefficient dropped significantly (r2 0.45). The interference of ICG on HSI imaging was clearly identified in the spectral curves.

Conclusion: StO2 given by HSI provided results comparable to those obtained with FLER in our bowel ischemia model, without the need to inject a contrast agent. ICG interferes with HSI datasets, disrupting StO2 values.

O110—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


M. Koshkin, O. Vasnev, A. Belousov, M. Baychorov, P. Agami High-tech surgery, Moscow Clinical Scientific Centre, MOSCOW, Russia

Surgical treatment is one of the most effective options for treatment of giant hiatal hernia. Laparoscopic approach became is a ‘gold standard’ over the time demonstrating all advantages of minimally invasive techniques over the open procedures. However the utility of robotic operations still remains controversial.

Aim of the study: Evaluate the initial experience of robotic fundoplication in compare to laparoscopic procedures.

Materials and methods: Since the January till the December of 2017 thirty operations were operated on. Mean age was 57.2 (44–76), among them 12 (65%) were female and 6 (35%) were males. Mean BMI was 29.4 (24.1–41.0). Laparoscopic procedures were performed in 8 patients (1st group), robotic procedures with DaVinci system were performed in 10 patients of the second group.

Nissen fundoplication modified was performed in 14 patients, Toupet fundoplication was used for 4 patients.

Results: The median operative time in laparoscopic group was 150 min, in robotic group—131,2 min. There were no statistical differences between two groups (p = 0.93).

Blood loss was minimal in both groups.

Mean postoperative hospital stay was 4.08 days (2–7 days) in the 1st group and 3,6 days (2–6 days) in the second. There were no statistical differences between two groups (p = 0.19).

Postoperative course was uneventful in all patients of both groups.

Conclusion: Robotic fundoplication is safe and effective method of treatment of giant hiatal hernia

Robotic surgery shows a number of advantages. Future multi-center studies should standardize intraoperative techniques.

O111—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


E. Yiannakopoulou Biomedical Sciences, University of West Attica, ATHENS, Greece

Surgical stress response is associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction syndrome. Robotic assisted surgery has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. These advantages could result in limited intra-abdominal trauma and hence in attenuated surgical stress response over conventional laparoscopy.

Aims: This study aimed to synthesize data on the effect of robot assisted surgery on surgical stress response.

Methods: Electronic databases were searched with the search terms ‘surgical stress’, ‘stress response’, ‘oxidative stress’, ‘robotic assisted surgery’, ‘c-reactive protein’, ‘interleukin 6’, ‘interleukin 10’,’cortisol’,;’oxidative stress markers’, ‘antioxidants’, ‘antioxidant status’, ‘MDA’, ‘glutathione’, ‘cortisol’, ‘acute phase response’ up to and including March 2018.

Results: One hundred forty studies were identified and their title and abstract were reviewed. One randomized controlled trial, six non randomized comparative studies, one experimental study and one case report met inclusion criteria. Data were discordant. One prospective trial concluded that cortisol and IL-6 were lower in laparoscopic assisted distal gastrectomy compared with robot assisted distal gastrectomy In another study comparing robotic assisted laparoscopic radical prostatectomy with open radical prostatectomy based on plasma measurements of IL-6, IL-1a and C-reactive protein, it was demonstrated that robotic assisted laparoscopic radical prostatectomy induces lower tissue trauma than open radical prostatectomy. In another study, it was reported reduced expression of genes associated with surgical stress response in patients treated with robotically assisted radical prostatectomy compared with patients treated with open prostatectomy. The case report concerned a case of polymyalgia rheumatic after robotic assisted laparoscopic prostatectomy. The experimental trial demonstrated that cortisol and substance P were significantly higher with open thoracic approach versus robot assisted thoracoscopic oesophageal surgery.

Conclusion: Further research is needed to elucidate the effect of robotic surgery on surgical stress, based on a well standardized protocol for the measurement of surgical stress response.

O112—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


G.M. Son Surgery, Yangsan Pusan national university hospital, YANGSAN SI, Korea

Purpose: Tissue compression is essential to prepare the tissue for proper staple formation. This study evaluates the risk factors of compression injury on the circular stapling line in vitro.

Methods: To reproduce the artificial bowel wall, a collagen plate was prepared by mixing collagen extracted from porcine with glycerin. Artificial collagen plates with 4 mm and 6 mm in the thickness were made for dry and healthy condition and immersed plates in the tap water for 10 min to make wet and edematous condition. Circular stapler (CDH25A, Ethicon, USA) was applied in the collagen plates (dry and wet condition) and optimal compressions. Compression line was evaluated for compression injury score. Risk factors for excessive compressions and unacceptable injury were analyzed.

Results: In the dry condition, optimal compression didn’t cause unacceptable injury. In the wet condition, excessive compressions were occurred in 47.1% with optimal approximation. unacceptable injury was significantly different in proper and excessive compression cases as 18.8% and 5.6%, respectively. On the univariate analysis, thickness (6 mm), wet condition, proximal side, maximal compression, and excessive compression were associated with unacceptable injury. On the multivariate analysis using Logistic regression model, excessive compression was significant independent factor to cause tissue injury (p < 0.001) and this significance was also proved in the optimal compression group (p = 0.021).

Conclusion: Excessive compression could result in unacceptable damage to the circular stapling line of thick tissue with edema and the careful guideline is required to reduce compression injury of stapling line for safe anastomosis for colorectal cancer patients.

Keywords: circular stapler, over-compression, compression injury, anastomosis, colorectal surgery

O113—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


M.A. Ismail Lotfallah 1, A. Shams1, A.h. Abdelghaffar1, A.H. Fawzy2, M. Maged1 1Pediatric surgery, Al Azhar university, GIZA, Egypt; 2Pediatric surgery, Beni suef University, BENI SUEF, Egypt

Background: Minimal invasive appendectomy gained much popularity due to its better cosmoses, early recovery and less wound site infections. Single incision laparoscopic appendectomy (SILA) has many disadvantages such as, long operative time, bad ergonomics, surgical site infections, high conversion rate and port site hernia. Needlescopic appendectomy (NA) using Mediflex® facial closure needle expected to be more superior over SILA. Here in we compare our results of needlescopic appendectomy with single-incision one.

Material and methods: one hundred and twenty patients with acute non complicated appendicitis were randomly assigned to NA and SILA 60 children for each group during the period between January 2015 to October 2018. The main outcome measurements included, demographics, operative time, intraoperative complication, conversion rate, post-operative hospital stay, surgical site infection, port site hernia and cosmetic results.

Results: A total of 120 children underwent appendectomy. There were 60 children who underwent NA and 60 children who underwent SILA. There were no difference in age (11.5 vs 11.98 years, P = 0.35), weight (42.98 vs 43.46 kg, p = 0.76) and hospital stay (1.51 vs 1.55 days, P = 0.92) between the two groups. There were no intraoperative complication during the two surgical approaches. Operative time for NA group is significantly shorter than Single incision group (20.7 vs 38.2 min, P = 0.0001). No single case of conversion in NA group and 18 cases needed conversion in SILA group. Seven cases of SILA showed surgical site infection. 2 cases of SILA group presented with port site hernia. The NA group was superior as regard ergonomics. The two groups showed equal excellent cosmetic results.

Conclusion: Needles scopic appendectomy and SILA are comparable as regard cosmetic results and hospital stay. NA proved to be safe, applicable, repetitive and superior over SILA as regard better ergonomics, less operative time, absence of surgical site infection and port site hernia.

O114—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


F.M. Sanchez Margallo 1, J.A. Sánchez Margallo2 1Scientific Direction, Minimally Invasive Surgery Centre, CÁCERES, Spain; 2Bioengineering, Minimally Invasive Surgery Centre, CÁCERES, Spain

Aims: To objectively analyze the surgical performance and surgeon’s ergonomics in the use of a novel flexible laparoscopic instrument during intracorporeal suture, and compare it with the use of a conventional laparoscopic needle holder.

Methods: Three experienced laparoscopic surgeons performed five laparoscopic sutures on an organic tissue using the novel flexible instrument (FlexDex®) and five sutures using a conventional needle holder with axial handle. The new device is based on a mechanical design with no electrical components, which transfers the surgeon’s hand, wrist, and arm movements to the instrument tip in an intuitive manner. The use of the instruments was organized in a random fashion. Prior to the study, participants conducted a 15-minute training session with the new flexible instrument. Execution time and quality of the suture were assessed for each repetition. Besides, flexion and radioulnar deviation of the wrist were recorded using an electrogoniometer (Biopac systems, Inc.) attached to the surgeon’s hand and forearm. The intensity of the forearm’s muscle activation was also analyzed by means of a MYO armband (Thalmic Labs).

Results: Surgeons required more time to perform the intracorporeal suture using the novel laparoscopic instrument (87.8 ± 23.333 s vs. 56.467 ± 8.733 s; p < 0.001), but the quality of the suture was similar with both instruments. The wrist flexion (9.976 ± 7.513° vs 15.440 ± 4.049°; p < 0.01) and wrist ulnar deviation (21.565 ± 5.19° vs 27.401 ± 3.19°; p < 0.01) were significantly lower when using the flexible instrument. During the suturing tasks, the use of FlexDex® instrument led to a higher muscular activation of the flexor (32.614 ± 3.437 vs 25.23 ± 3.076 RMS; p < 0.001) and extensor (23.341 ± 1.869 vs 20.017 ± 1.307 RMS; p < 0.001) muscle groups of the forearm.

Conclusions: The presented novel instrument allows surgeons to perform robotic-like laparoscopic suturing. We believe that with a longer training period surgeons could potentially reduce surgical times with this device. The preliminary results of this study suggest that the use of this new instrument provides a quality of the suture similar to that obtained with a conventional laparoscopic needle holder and an ergonomically more adequate wrist posture.

O115—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


A. Studier-Fischer 1, K.F. Kowalewski1, F.M. Schwab1, C. Haney1, I. Gockel2, F. Nickel1, B.P. Müller-Stich1 1Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, HEIDELBERG, Germany; 2Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, LEIPZIG, Germany

Aims: The intraoperative real-time evaluation of tissue perfusion is one key element for successful visceral surgery. Traditionally, tissue evaluation is performed visually by surgeons. Newer devices for objective quantification have in majority been based on the application of the fluorescent dye indocyanin green (ICG). A novel method derived from geographic research is Hyperspectral Imaging (HSI). The aim of this study was the evaluation of HSI as a promising method for the evaluation of tissue perfusion and its implementation in the evaluation of the gastric conduit during esophagectomy in a porcine model.

Methods: The HSI camera records a 3 dimensional data cube from a 2 dimensional surgical situs obtaining wavelengths between 500 and 1000 nm. The absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. A software calculates 4 different indices in real-time including oxygen saturation. A porcine model (n = 24) is used for esophagectomy with gastric conduit formation. Ischemia is induced artificially by magnets simulating staplers. Different shapes of the gastric conduit and anastomosis formation are evaluated for perfusion metrics in order to obtain recommendations for the optimal formation of esophagogastrostomy.

Results: In preliminary results the perfusion measurements showed impaired tissue oxyen saturation after longitudinal stapling in the distal gastric conduit (pre-stapling: mean = 62.5%, 95% CI [58.9%, 66.1%], post-stapling after 2 min: mean = 52.2% 95% CI [49.9%, 54.5%], p < 0.0001) whereas tissue oxygen saturation remained unchanged after transverse stapling in the gastric conduit (pre-stapling: mean = 71.2%, 95% CI [68.7%, 73.7%], post-stapling after 2 min: mean = 72.4%, 95% CI [69.9%, 74.9%], n.s.).

Conclusion: HSI is a promising method for intraoperative evaluation of tissue perfusion that does not require application or injection of any agents. The preliminary results in this study showed that the gastric conduit receives its main blood supply from the gastroepiploic arteries and not via the mucosa. Further results from the current evaluations enable formation of an optimized gastric tube and esophagogastrostomy in esophagectomy.

O116—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


M.A. Ismail Lotfallah 1, A.H. Fawzy2, M. Maged1, A. Shams1 1Pediatric surgery, Al Azhar university, GIZA, Egypt; 2Pediatric surgery, Beni suef University, BENI SUEF, Egypt

Background: varicocele is one of the most common causes of infertility. Many surgical interventions are used for varicocele ligation including open and conventional laparoscopic multiport or single incision techniques. The aim of the study is to present a new Needlescopic lymphatic sparing varicocele ligation using Mediflex® facial closure needle and 14 gauge vascular access cannula.

Material and Methods: twenty-two male children with bilateral varicocele of grade II–III. All children were counseled by Clinical examination, Doppler ultrasonography, abdominal ultrasonography, and routine laboratory investigations. Testicular lymphatics were delineated by subcutaneous injection of 1/2 cm3 methylene blue in anterior wall of the scrotum 20 min prior to surgery. The testicular vessels (both vein and artery) were ligated one cm above the deep inguinal ring using two Mediflex needles with preservation of lympatics. The main outcome measurements included; operative time, hospitalization, testicular atrophy, hydrocele formation, recurrence of varicocele and intra or postoperative complication.

Results: a total of twenty-two male children with grade II–III varicocele subjected to needlescopic lymphatic sparing technique. Twenty one were bilateral. 15 cases were grade III and 7 cases were grade II. Patient’s age ranged between 8 and 16 years (mean 11.86 years ± 2.96). The mean operative time was 32.59 ± 9.42 min. The mean hospital stay period was 1.77 ± 0.75 days. No single case of conversion to either open or multiport laparoscopic technique. No intra-operative complications. One case complicated by hydrocele which resolved by expectant treatment. Excellent cosmetic results were gained with good family satisfaction. Testicular volume measurements proved absence of testicular atrophy. Recurrence was detected in only one case, treated by selective embolization of abnormal communicating vein to the cremastric veins.

Conclusion: This study proved that needlescopic varicocele ligation technique is safe, effective, reproducible, less time consuming with fantastic minimally invasive cosmetic results.



R. Caruso, E. Vicente, Y. Quijano, H. Duran, B. Ielpo, I. Fabra, E. Diaz, L. Malave, R. Isernia, E. Pinna, V. Ferri General Surgery, Sanchinarro University Hospital, MADRID, Spain

Background and Aims: Even if the clinical outcomes of robotic rectal resections are under investigation, the related robotic costs have not yet been well addressed, and the differences between the robotic rectal resection costs and the laparoscopic approach are still not well known.

We have therefore performed a prospective comparative study of robotic rectal resections (RRR) and laparoscopic rectal resections (LRR) performed at our centre with the aim to evaluate the cost-effective outcomes of robotic versus laparoscopic surgery.

Study design: This is an observational, comparative prospective non-randomized study which includes patients that underwent laparoscopic and robotic rectal resection reaching a minimum of 6 months of follow up from February 2014 to March 2018, at the Sanchinarro University Hospital, Madrid. An independent company performed the financial analysis and fixed costs were excluded. Outcome parameters included surgical and post-operative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER). The primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups.

Results: A total of 86 RRR and 112 LRR were included. The mean operative time was significantly lower in the LRR approach (336 versus 283 min; p = 0.001). The main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (RRR: 5.8%, LRR: 11.6%;p = 0.001).The mean operative costs were higher for RRR (4285.16 versus 3506.11€; p = 0.04); however, the mean overall costs were similar (7279.31€ for RRR and 6879.8€ for the LLR; p = 0.44). Mean QALYs at 1 year for RRR group (0.5624) was higher than that associated with LRR (0.5066) (p = 0.018). At a willingness-to-pay threshold of 20,000 € and 30,000 €, there was a 61.18% and 64.09% probability that RRR group was cost-effective relative to LRR approach.

Conclusion: This study provides data of cost-effectiveness differences between RRR and LRR approach showing a benefit for the RRR



M. Ortenzi 1, R.O. Ghiselli1, A.N. Carrieri1, G.I. Lezoche1, A.N. Balla2, A.M. Paganini2, M.A. Guerrieri1 1Clinica Chirurgica, Università Politecnica delle Marche, ANCONA, Italy; 2Department of General Surgery and Surgical Specialties, Paride Stefanini, Sapienza University of Rome, ROMA, Italy

Aim: The efforts were aimed to the introduction of novel surgical technologies to overcome the intrinsic anatomical and technical constraints of rectal surgery. This was the case of the introduction into the clinical practice of laparoscopy and later on of robotic surgery for rectal surgery. However, whether robotic surgery is actually superior to laparoscopy is still debated. The aim of this study was to compare 3D laparoscopy and robotic surgery for rectal cancer on technical and oncological outcomes.

Methods: This was a single-center, prospective, randomized controlled trial. All patients more than 18 years of age undergoing elective surgery for rectal cancer situated from 5 to 10 cm from the anal verge were included. Patients undergoing abdominal perineal amputation and/or with T4 and/or M1 tumours were excluded. Patients were randomized before surgery into two arms: arms A (3D laparoscopy) and arm B (robotic), and gave their consensus to the study. Demographic data, data regarding the tumour, operative and post-operative data were collected. Patients with a follow up shorter than 24 months were excluded as well.

Results: Twenty patients were enrolled in arm A and 20 in arm B in the period time of one year. Patients’ population of the 2 arms was homogeneous as concerns demographic characteristics and stage of the disease. Robot-assisted rectal resection results in comparable operative time (125.70 vs 170 min; p = 0.068). The conversion rate was significantly lower for arm B (2 vs 0 p = 0.0). Postoperative morbidity was comparable between groups. Hospital stay was comparable but time required to resolve post-operative ileus was shorter in arm B (2.5 vs 1.2 days, p = 0.048). Overall survival and disease-free survival were comparable between arms (98.6% vs 98.3%, p = 0.989, and 97.4% vs 97.6%, p = 0.856, respectively)

Conclusions: 3D laparoscopy and robotic surgery are two viable options for rectal surgery. Robotic surgery can add some in terms of post-operative outcomes and ergonomics.



Y. Tsuchiya 1, Y. Okazawa1, K. Mizukoshi1, M. Kawai1, K. Sugimoto1, H. Kamiyama1, M. Takahashi1, Y. Kojima1, Y. Tomiki1, T. Fukunaga2, Y. Kajiyama2, K. Sakamoto1 1Coloproctological Surgery, Juntendo University Faculty of Medicine, TOKYO, Japan; 2Gastroenterological Surgery, Juntendo University Faculty of Medicine, TOKYO, Japan

Aim: Currently, robotic surgery for rectal cancer is a surgical operation that is being performed worldwide. We also introduced robotic surgery in 2015. However, after robotic surgery, we observed a rise in creatinine kinase (CK), which is unlikely to happen in other surgeries. We studied the postoperative complications of rectal cancer patients who underwent either robotic surgery or laparoscopy during the same period of time.

Methods: From January 2016 to November 2018, 23 patients underwent surgery using robot-assisted rectal resection (da Vinci Si 20 cases and Xi 3 cases) and 33 patients underwent laparoscopic rectal resection. In this study, abdominoperineal resection, intersphincteric resection, and lateral lymph node dissection were excluded.

Result: The operation time for the robotic surgery group was significantly longer than that for the laparoscopic group (424 min vs. 305 min; p < 0.001). The CK value of the robotic surgery group on 1POD was significantly higher than that of the laparoscopic group (525 IU/L vs. 160 IU/L; p < 0.001). In addition, one case of compartment syndrome was observed in the laparoscopic group. There were no significant differences in age, body mass index, intraoperative bleeding, tumor invasion depth, urination disorder, or postoperative hospital stay. In robotic surgery, it is considered that the increase in CK value is caused by the extended operation time, contact of the patient’s cart with the left thigh of the patient, and the extra force applied to the abdominal wall caused by the displacement of the remote center.

Conclusion: In robotic surgery, it is suggested that the measurement of postoperative CK value is important. Therefore, an attempt to shorten the operation time and paying attention to the surgical field are necessary to improve the outcomes.



T. Petropoulou, S.N. Amin Colorectal Surgery, Sheffield Teaching Hospitals, SHEFFIELD, UNITED KINGDOM, United Kingdom

Aim: The aim of this study is to investigate whether the robotic platform can have a positive impact in sphincter preservation in pts with low rectal tumours, undergoing robotic TME, in comparison with laparoscopic or open TME

We also analyzed and compared short term outcomes

Methods: A prospectively collected robotic database was reviewed and compared with the trust data. This includes all rectal resections which were performed with the robotic platform, over a period of 4 years, versus the trust data for the same period.

Results: 270 patients were analyzed.Groups were matched for distance from the anal verge.Demographics for the groups (sex, age, BMI) were similar.

The percentage of APER (abdominoperineal resection) rate was significant less in the robotic group (11% vs 43%, p < 0.001)Median LoS, complication rate, CRM (+) rate for the robotic group was also statistically significant lower in all subgroup analyses. Specimen quality (TME grade, depth of mesocolon, LN harvested) was better for thre robotic group.

Conclusion: Robotic surgery for rectal cancer is safe and feasible, and could help surgeons perform ultra low rectal resections, rather than APER’s and save patients sphincters. CRM (+) rate is low, which could lead to improved oncological outcomes.

Key statement: This is one of the biggest databases for robotic rectal cancer resections in UK (awaits publication in peer reviewed journal) Our data for short term outcomes are favorable over previously published data.Specimen quality and long-term outcomes were better which could lead to improved oncological outcomes too.



Y. Tao 1, I. Alarcon1, V. Camacho1, G. Martin2, C. Moreno3, J. Noguera4, X. Sierra5, B. Flor6, S. Morales-Conde1 1Unit of innovation in Minimally Invasive surgery. Unit of General Surgery, University Hospital Virgen del Rocio, SEVILLA, Spain; 2Unit of General and Digestive Surgery, University hospital Son Espases, PALMA DE MALLORCA, Spain; 3Unit of General and Digestive Surgery, Hospital La Mancha Centro, ALCÁZAR DE SAN JUAN, Spain; 4Unit of General and Digestive Surgery, University Hospital A Coruña, A CORUÑA, Spain; 5Unit of General and Digestive Surgery, C.C.S.Parc Tauli, BARCELONA, Spain; 6Unit of General and Digestive Surgery, University Hospital La Fe, VALENCIA, Spain

Aims: Anastomotic leak remains as one of the most important and life threatening post-operative complications in colorectal surgery. This complication has important consequences, both acute and long term, longer hospital stay, re-intervention, and increased morbidity and mortality. Among all different circumstances that have been related to this entity, blood supply is an important factor that might have influence. Fluorescence with indocyanine-green (ICG) is used as a marker in the assessment of tissue perfusion in colorectal surgery which might reduce the numbers of leaks.

Methods: A multicenter analysis of the experience of 5 centers in Spain is collected in order to assess the value of ICG in colorectal anastomosis. 379 colorectal procedures were performed using ICG to evaluate vascular supply in the anastomosis. ICG was infused before performing the anastomosis analyzing the number of cases in which the transection line (TL) was changed. We also analyzed the number of leaks in those cases that we changed this line.

Results: Out of the 379 cases performed, 15 cases were performed by open surgery, 319 by laparoscopy, 35 by single-port and 10 with Transanal total mesorectal excision(TATME). The following procedures were performed: 94 right colonic resection(RC), 9 splenic flexure partial resection(SF), 149 left colonic resection(LC), 3 Subtotal colectomy(SC), 2 total colectomy(TC), 6 Hartman reversal surgery(HR), 63 Low anterior resection with partial mesorectal-escision(LAR) and 47 Ultra low anterior resection with total mesorectal-escision(ULAR). Leak rate(LR) was 6.59% (3.19%RC, 5.36%LC, 33.33%SC, 11.11%LAR, 11.32%ULAR). Overall LR was 4.3% in colonic surgery and 11.2% in rectal surgery. The TL was changed due to ICG in 12.13% of the cases (4.25%RC, 11.1%SF, 16.77%LC, 50% TC, 7.93% LAR, 18.86% ULAR), being 11.9% in colonic resection and 12.9% in rectal resection. The relation between leaks and the cases in which the TL was changed, were 20% (33.3%RC, 25%LC, 33.3%ULAR).

Conclusion: ICG fluorescence may play a role in anastomotic tissue perfusion assessment. The LR after colorectal surgery might decrease using ICG to detect the proper TL before to perform the anastomosis. However, we do not have the sufficient evidence to determine that the changing transaction line can lead to avoid leaks.



P. Tejedor, J.S. Khan, F. Sagias Colorectal Surgery, Queen Alexandra Hospital, PORTSMOUTH, United Kingdom

Aims: To analyse the value of postoperative day 2 CRP as an early predictor of safe discharge in robotic rectal cancer surgery.

Methods: A retrospective analysis was performed, including patients who had undergone robotic total mesorectal excision (TME) in a single centre over a 4-year period (May 2013—September 2017). Patients who had a permanent stoma (abdominperineal resections or Hartmann’s procedure) were exluded from the study, leaving 144 patients for further analysis.

As the LOS is currently used as a performance tool in assessing outcomes in colorectal surgery (with a cut-off established at 5 days), we compared the CRP values in these 2 groups.

Results: Fourty one percent of patients were discharged home within 5 days. They had an earlier peak of CRP on postoperative day (POD) 2 (median 94.5, 80).

The group of patients that were discharge home after 5 days (59%) had a CRP peak on POD 3 (median 151, 168).

On POD 3, the group of patients that went home within 5 days had a lower CRP (83–70- vs. 151–168-) compared to the group of patients that were discharge after 5 days, p = 0.001).

Conclusions: A CRP peak on POD 2 in robotic TME can predict an early and safe discharge (LOS within 5 days).



H.J. Kim, G.S. Choi, J.S. Park, S.Y. Park Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, DAEGU, Korea

Background: PurposeLateral pelvic lymph node dissection (LPND) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (CRT). However, technical difficulties make it possible that lateral pelvic lymph nodes (LPNs) are not dissected completely and, thus, remained in the narrow pelvis. Near-infrared fluorescence imaging (FI)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. This study aimed to evaluate the efficacy of FI using indocyamine green (ICG) to identify LPNs during robotic LPND.

Methods: 31 rectal cancer patients who were suspected LPN metastasis and had received preoperative CRT were prospectively enrolled. ICG in a dose of 2.5 mg was injected around tumor preoperatively. All procedures were performed with a totally robotic approach. After completing LPND, FI was checked again for identifying remained LPNs and resecting them completely.

Results: The LPNs were successfully detected in 25 (80.6%) of the 31 patients. However, after accounting for eight cases, having finished adjusting ICG injection, the LPNs were successfully detected in 22 (95.7%) of 23 patients. The FI-guided LPND group (N = 25) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic LPND (N = 62). However, the mean number of unilateral harvested LPNs was 10.2 in the FI-guided LPND group, which was greater than the mean of 6.6 in the conventional group. LPN metastasis was identified in 40% of the FI-guided LPND group, which was higher than that of the conventional group, 31.7%.

Conclusion: FI-guided LPND identifies lymph nodes in pelvic side-wall with great reliability. This contributes to increased number of LPNs yield compared to conventional robotic LPND. This technique should be considered to dissect them completely by preventing subsequent missing of nonvisible LPNs.



P. Tejedor, F. Sagias, K. Flashman, J.S. Khan Colorectal Surgery, Queen Alexandra Hospital, PORTSMOUTH, United Kingdom

Aims: To compare the medium-term oncological outcomes of Laparoscopic Total Mesorectal Excision (L-TME) vs. Robotic Total Mesorectal Excision (R-TME) for rectal cancer.

Methods: A retrospective analysis was performed including patients who underwent L-TME or R-TME resection between 2011-2017. Patients with disease stage IV at diagnosis or R1 resection were excluded. 680 patients were initially included, and 136 cases of R-TME were matched based on age, gender, stage and time of follow-up with an equal number of patientswho underwent L-TME. We compared 3-year disease free survival (DFS) and overall survival (OS).

In adittion, a multivariate analysis was performed in order to idenfity independent prognostic factors for 3-year DFS and OS.

Results: Pathological outcomes were similar between groups. However, major complications were lower in the robotic group (13.2% vs. 22.8%, p = 0.04), highlighting the anastomotic leakage rate, which was 7.4% in the R-TME vs. 16.9% in the L-TME group (p = 0.01).

Overall, the 3-year DFS rate was 69% in the laparoscopic group and 84% in the robotic group (p = 0.02). The 3-year OS rate was 70% in the L-TME groups and 97% in the R-TME group (p = 0.000).

For disease stage III, 3-year DFS was significantly higher in the R-TME group. OS was also significantly superior in the robotic group for every stage, reaching 86% in the stage III.

In the multivariate analysis, R-TME was a significant positive prognostic factor for distant metastasis (OR 0.2 95%CI 0.1, 0.6, p = 0.001) and OS (OR 0.2 95%CI 0.07, 0.4, p = 0.000).

Conclusions: R-TME for rectal cancer can achieve better oncological outcomes compared to L-TME, especially in stage III rectal cancers. The robotic approach has demonstrated to be a significant positive prognostic factor for local recurrence and overall survival, due to the better postoperative outcomes. However, a longer follow-up period is needed to confirm the oncologic findings.



V.N. Uslar 1, F. Piastowski1, T. Vajsbaher2, D. Weyhe1 1University Hospital for Visceral Surgery, University of Oldenburg, OLDENBURG, Germany; 2Bremen Spatial Cognition Center, University of Bremen, BREMEN, Germany

Aims: In clinical settings, realistic assessment of one’s own abilities can enhance performance and promote patient safety, especially in surgical residents, who inevitably have to acquire skills during real surgery. This study thus implemented the Global Assessment of Laparoscopic Skills (GOALS) questionnaire with the aim to explore divergences between resident self-evaluation and specialist’s evaluation on laparoscopic performance, as a first step to implement the GOALS questionnaire as a tool for constructive and objective feedback.

Methods: Between July and October 2018, seven residents from the University Hospital for Visceral Surgery at the Pius-Hospital Oldenburg participated in this study. At the end of every laparoscopic operation where the resident acted as the primary surgeon, the resident and the supervising surgeon independently evaluated the resident’s operative performance using the GOALS questionnaire. The five dimensions evaluated were depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. A cumulative GOALS-Score (with 25 being the highest possible score) was calculated for n = 46 laparoscopic operations. Resident’s year of training, the level of case difficulty and the type of laparoscopic procedure performed was also analysed.

Results: Residents overestimated their laparoscopic abilities in 64.4% of the operations (GOALS-Scores: residents: median = 16, mean = 16.51; specialists: median = 15, mean = 14.60; p < 0.001). Residents in the first three years of surgical training were more likely to overestimate their performance (residents: median = 16.5, mean = 16.82; specialists: median = 13, mean = 13.14; p < 0.001) than those with more than three years of surgical experience (residents: median = 16, mean = 16.22; specialists: median = 15, mean = 16.00; p = 0.613). GOALS score differences did not depend on case difficulty and laparoscopic procedure.

Conclusions: Surgical residents tend to overestimate their intraoperative laparoscopic performance when compared to specialist evaluation. Overestimation was found to depend on one’s own laparoscopic experience and seem to disappear with gained expertise. These results signify the importance of individually adapted training and the greater need for objective feedback for surgical residents. This approach could in return increase the skill acquisition rate of the resident and in return contribute towards enhancing patient safety.



A.S.H.M. van Dalen 1, M. Goldenberg2, T.P. Grantcharov3, M.P. Schijven1 1Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, AMSTERDAM, The Netherlands; 2Department of Urology, International Centre for Surgical Safety, St Michael’s Hospital, University of T, TORONTO, Canada; 3Department of Surgery, International Centre for Surgical Safety, St Michael’s Hospital, University of T, TORONTO, Canada

Introduction: The delivery of safe surgical care is dependent of various, complex and interrelated factors. Substantial data exist regarding the impact of training in human factor skills on surgical outcomes. However, except for the standardized time-out process, the best way to go about improving these skills remains unclear. The aim of this study was to gain more insights in the theatre staff’s perception of human factors and their importance on surgical outcome in the operating theatre.

Methods: The Surgical Team Assessment Record (STAR) questionnaire was used to study the role of human factors, such as communication, situational awareness and organization, contributing to surgical team performance. The self-assessment questionnaire was filled out by the theatre staff, directly after the surgical procedure. Conditional logistic regression was used to identify the impact of the role in the operating theatre on the yes versus no answers.

Results: Some 507 questionnaires were completed. The theatre staff rated their team’s performance with a median of 4 (IQR 0.0, 5-point Likert scale). The surgical fellows (N = 76) rated their personal factors significantly lower compared to the rest of the operating team (median 3 versus 4, P-value < 0.0001). The staff surgeon (N = 119) indicated significantly more often that there were many distractions (51.3%, yes n = 61) and noticed aberrations (60.5%, yes n = 72) during the surgical procedure (P-value < 0.0001) when compared to the rest of the operating team. Most aberrations reported by the surgeons were related to technical performance.

Conclusions: Human factors play an important role in the surgical environment. Situational awareness may be less developed in members of operating teams, compared to the surgeon of that team. Further work is needed to elucidate the impact of human factor skills on team performance. A team-based approach to safety interventions is recommended. Future studies should determine what type of aberrations and distractions are most relevant and valuable to embark on with team training.



T. Iwata 1, K. Yoshikawa2, J. Higashijima2, T. Miyatani2, T. Tokunaga2, M. Nishi2, H. Kashihara2, C. Takasu2, M. Shimada2 1Dept. of Digestive Surgery, School of Medicine, Tokushima University, TOKUSHIMA, Japan; 2Dept. of Digestive Surgery, Tokushima University, TOKUSHIMA, Japan

Background: The qualitative evaluation for laparoscopic training of medical students was performed using Rubric evaluation, and weak points in conjunction with the lack of anatomical knowledge were derived. To conquer these weak points, virtual reality (VR) + augmented reality (AR) training for understanding of regional anatomy was investigated.

Materials and methods: One hundred and six students in 5th grade of Tokushima Univ. participated basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator. Rubric evaluation, as qualitative evaluation, which includes the evaluation standards for each maneuver were performed before and after basic task training and sham operation. The group which self-evaluation was higher in a Rubric evaluation was investigated.

The 3D image of vessels and bile duct obtained from MDCT of real patient was projected in reality space with Microsoft HoloLens. Training of AR image using HoloLens was performed for understanding of regional anatomy. After training of regional anatomy with HoloLens, sham laparoscopic cholecystectomy was performed again, and quality of procedure was evaluated by Rubric. Anatomical questions were.

Results: Rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. In sham laparoscopic cholecystectomy, several students showed higher score than tutor, especially in part of extension of operation field by elevation of the Gall bladder, exposure of triangle of Calot, and exposure of cystic duct.

After AR training, all students showed high score in questions related regional anatomy during operation. Especially, rubric evaluation of students who showed high self-evaluation in sham operation showed same score with tutor.

Conclusions: As Rubric evaluation showed weak points of detailed parts of maneuver, and VR + AR was useful for understanding details of regional anatomy for laparoscopic training.



N.J. Curtis1, G. Dennison2, J.A. Conti3, G.B. Hanna1, N.K. Francis2 1Surgery and Cancer, Imperial College London, LONDON, United Kingdom; 2General Surgery, Yeovil District Hospital, YEOVIL, United Kingdom; 3Colorectal Surgery, Portsmouth Hospitals NHS Trust, PORTSMOUTH, United Arab Emirates

Background: The EAES has recently published an intraoperative adverse event classification to aid reporting of minimally access surgery events. This includes capture of non-consequential errors. We aimed to investigate the clinical impact of these apparent ‘near miss’ events.

Methods: Case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision randomised controlled trial was utilised (ISRCTN59485808). The EAES classification was applied by two blinded assessors to all enacted adverse events identified on video analysis using the observational clinical human reliability analysis technique. The total number of grade 1 (non-consequential) errors were compared with the number and nature of 30 day morbidity events (graded with the Clavien-Dindo system) and length of stay.

Results: 77 cases (419 h of surgery) contained 1377 error events of which 809 (58.8%) were classified as EAES grade 1 (median 10 per case, interquartile range 7–13, range 1–28). There were significantly more inconsequential errors recorded in patients that developed any early morbidity event than those who had an uneventful post-operative recovery (median 8.5 (IQR 6–12) vs. 11 (9–14), p = 0.005). A stepwise increase in the sum of EAES grade 1 errors is seen for each additional 30 day morbidity event reported (8.5 vs. 11 vs. 11 vs. 12, p = 0.047) and the highest Clavien-Dindo grade experienced (9 vs. 10 vs. 11 vs. 12. P = 0.067). Positive correlation is observed between the sum of EAES grade A errors and length of post-operative stay (rs = 0.36, p = 0.001).

Conclusion: In the context of major laparoscopic surgery, near misses are commonplace and correlate with surgical outcomes. This may represent a novel surrogate assessment method for intraoperative performance.



A. al-Jabir 1, A. Mondal2, D. Hubail2, T. Ward2, B. Patel2 1Barts and the London School of Medicine and Dentistry, QMUL, Barts Cancer Institute, LONDON, United Kingdom; 2Barts Cancer Institute, Barts Cancer Institute, LONDON, United Kingdom

Aims: Diagnostic laparoscopy (DL) is an under-utilised procedure that can replace non-therapeutic exploratory laparotomies in many contexts. To date, no validated education programme for DL exists. This study seeks to evaluate the feasibility, acceptability and face, content, construct validity of the LAPLAT curriculum (Laparoscopic learning for abdominal trauma; a simulation-based curriculum for Trauma DL). This is in addition to the development of a novel 3D-printed bench-top model for abdominal inspection.

Methods: This prospective and observational pilot study involved 39 novice medical students and junior doctors. Surgeons from the UK and international (n = 8) were involved in a two stage Delphi-process to determine the components of the training course which were used to formulate a final curriculum. In the absence of an adequate model for abdominal inspection, a novel 3D-printed abdominal inspection model was designed and produced. After an introductory familiarisation session as well as pre-course cognitive lectures, the novices performed 6 tasks on a virtual reality and bench-top simulator with 5 repetitions of each in a half-day session. Outcome measures for construct validity were total time to complete task, accuracy, percentage of horizon maintained and economy of movement. Face and content validity as well as acceptability was evaluated by a qualitative and quantitative survey.

Results: Face, content and construct validity as well as acceptability was established. Face validity was demonstrated in all components of the course (including pre- course cognitive content and technical tasks) in addition to content validity. All also met an acceptability threshold of 3/5 on a 5-point Likert scale. One-way ANOVA tests demonstrated construct validity in all tasks (p < 0.0002) with learning curves in reducing time observed. Using a performance improvement metric, one-way ANOVA tests showed similar rates of improvement per participant between most tasks (p > 0.05). The course was rated overall mean 8.86/10 (± 1.05).

Conclusion: This pilot study has demonstrated the feasibility, acceptability and face, content and construct validity of the LAPLAT curriculum as well of the novel 3D-printed abdominal inspection model. Randomised controlled trials are needed to establish higher-quality evidence, as part of a wider curriculum with transfer needed to the clinical environment.



C. Popa 1, C. Pestean2, C. Ober2, F. Graur1, M. Socaciu3, R. Couti4, T. al Momani5, R. Elisei5, F. Zaharie1, N. al Hajjar1, L. Oana2 1Surgery, Regional Institute of Gastroenterology and Hepatology, CLUJ-NAPOCA, Romania; 2Anesthesiology-Surgical Propedeutics, University of Agricultural Sciences and Veterinary Medicine, CLUJ-NAPOCA, Romania; 3Radiology, Regional Institute of Gastroenterology and Hepatology, CLUJ-NAPOCA, Romania; 4Urology, Training and Research Center, Prof. Dr. Sergiu Duca, CLUJ-NAPOCA, Romania; 5General Surgery, Training and Research Center, Prof. Dr. Sergiu Duca, CLUJ-NAPOCA, Romania

Aims: To evaluate the benefits of systematical use of ex vivoliver model and CT imaging in the planning process for swine laparoscopic liver resections done by residents during training programs.

Methods: Twenty four general surgery residents were equally divided into two groups: first one which performed laparoscopic liver resections without planning stage and the second one which systematically used anatomical data from a swine liver model and interactive CT scans 3D reconstructions. The planning stage included an interactive tutorial for establishing the strategy for the next resection followed by performing open liver dissection and the same resection on an ex vivoswine model. A total of twelve models were used during this step. Afterwards, laparoscopic procedures were performed on sixteen anesthetized domestic pigs, two swine for every team, composed of three residents. Both groups were part of a dedicated and continuous training program and used the same ‘step by step’ protocol for resections.

Results: The average time for imagistic planning was 36.7 min and for open dissection and resection was 57.9 min. All teams successfully completed the interventions and followed the standardized protocol without trainers’ interventions and with no conversions. The second group obtained better results regarding the time needed for completion and blood loss. Also, when the planning stage was applied the resection was more accurate and less functional parenchyma was removed.

Conclusion(s): The ‘warming up’ by adding the imagistic and anatomical data to the core protocol offer more clarity before laparoscopic liver resections. This also makes an upgrade for our ‘step by step’ protocol and provides sufficient data to admit this planning stage as mandatory for laparoscopic liver resection on swine during a training program.



L. Seifert 1, K.F. Kowalewski1, M.W. Schmidt1, B. Müller1, K.F. Köppinger1, B.P. Müller-Stich2, F. Nickel1 1Department of Surgery, Heidelberg University, HEIDELBERG, Germany; 2Department of General, Visceral and Transplant Surgery, University of Heidelberg, HEIDELBERG, Germany

Background: Conventional surgery which used to be gold standard for many years was replaced by Minimal Invasive Surgery (MIS) because it comes with benefits for the patients. For the surgeon it comes with obstacles, therefore many training curricula were established, aimed to train motoric skills. Situation awareness (SA) is a skill of effective information processing. It depends on common cognitive abilities and can be divided in three steps (1) perception of clues (2) connecting clues with knowledge for understanding their relevance (3) predicting possible outcomes. Good SA is required for adequate decision-making, consequently good SA is necessary in surgery to predict and avoid complications. This study aims to prove the potential benefit of SA training to the MIS trainings curriculum.

Methods: This was a prospective, single-centre, two-arm, parallel-group randomized trial which was conducted during MIS training for medical students in year 3-5. Participants were blinded until training was finished and computer based randomized. Before and after the intervention the performance on a simulated cholecystectomy (SC) was measured with OSATS and GOALS. Video sessions showing difficulties during the SC were shown to both groups. Active participation in the intervention group was achieved by including questions into the videoclips, aiming to train the tree steps of SA. The control group got to see the same videoclips without interceptive questions.

Preliminary results: There was no significant result for either the GOALS score (18.5 ± 4.6/18.7 ± 5.4; p = 0.981) or the OSATS score (62.23 ± 12.79/57.25 ± 9.36; p = 0.348) or the needed time (64.5 ± 22.0/62.8 ± 15.8; p = 0.62).There were correlations between the self-assessed attention and GOALS score (R = 0.1; R2 = 0.021) OSATS score (R = 0.2; R2 = 0.0325) and the time (R = − 0.0836; R2 = 0.007).The correlations between the right answered questions during the intervention and the different scores varied. The GOALS score had a slightly positive correlation (R = 0.1; R2 = 0.0126) whereas the OSATS score had a slightly negative correlation (R = − 0.3; R2 = 0.06699). Time did not show a relation to the right answered questions yet (R = − 0.1; R2 = 0.006).

Conclusion: The SA training doesn’t show significant results in different scores and time yet, but the individual assessment of the cognitive training requested through a questionnaire was higher in the group which trained situation awareness.

O132—ROBOTICS & NEW TECHNIQUES—Flexible surgery


P.W.Y. Chiu, H.C. Yip, A.Y. Teoh, S.M. Chan, S.K.H. Wong, E.K.W. Ng Department of Surgery, The Chinese University of Hong Kong, HONG KONG

Introduction: Submucosal tunnel endoscopic resections (STER) had been increasingly performed for treatment of gastric subepithelial tumors. One of the limitations for STER is the risk of incomplete tumor resection due to close dissection and bridging of tumor capsule. Endoscopic full thickness resection (EFTR) allowed complete resection of the tumor with margins to prevent recurrence. This study aimed to review the techniques and outcomes of EFTR for treatment of gastric subepithelial tumors.

Method: Patients who received endoscopic resection for gastric subepithelial tumors were recruited. The gastric subepithelial tumors were considered eligible for endoscopic resection with size < 40 mm. All patients received preoperative assessments including EUS and CT scan to define the extend of tumors and the proportion of extra and intralumenal components. All the procedures were performed under general anesthesia with CO2 insufflation. EFTR started after injection with mucosal incision up to 50% of tumor circumference, followed by submucosal dissection to identify tumor margin. Further dissection was performed using ESD devices. After adequate exposure of lateral margins, incision into muscularis propria was performed to achieve full thickness resection. Luminal defects were closed by either clips, clip-loop crown method or Overstitch suturing.

Results: From 2012 to 2018, 10 patients received EFTR for gastric subepithelial tumors. The mean age was 60.6 years, and 4 were male. The GIST were located at greater curvature (4), cardia (3), lesser curve (2) and antrum (1). The mean size was 20.5 mm (10—50 mm). Most of the EFTR were performed in operation theatre while two were done at endoscopy. The mean hospital stay was 4.5 days, and mean operative time was 98 min (34-180 mins). There was no conversion to laparoscopy. Closure of luminal defect were performed mostly with clips (5), followed by Overstitch (4) and clip and loop crown closure (1). Most patients resumed full diet on day 3, and all the pathologies confirmed GIST tumors with clear resection margins.

Conclusion: Endoscopic Full Thickness Resection is technically feasible and safe procedure for treatment of gastric GIST. Future research should focus on refining the techniques of EFTR and closure of the defect.

O133—ROBOTICS & NEW TECHNIQUES—Flexible surgery


S. Katsuyama 1, Y. Miyazaki2, S. Kobayashi3, K. Yamamoto4, Y. Nakagawa4, T. Takahashi2, K. Tanaka2, T. Makino2, Y. Kurokawa2, M. Yamasaki2, M. Mori2, Y. Doki2, K. Nakajima1 1Next Generation Endoscopic Intervention (Project ENGINE), Osaka University, SUITA, Japan; 2Gastroenterological Surgery, Osaka University, SUITA, Japan; 3Research & Development, 3-D Matrix, Ltd., CHIYODA-KU, TOKYO, Japan; 4Research & Development, FUSO Pharmaceutical Industries, Ltd., CYUOU-KU, OSAKA, Japan

Background: Hemostatic peptides have received increased attention. Self-assembling peptides (TDMs) comprise synthetic amphipathic peptides that immediately react to changes in pH and/or inorganic salts to transform into a gelatinous state. Since TDMs do not carry a risk of infection, their clinical application as new hemostatic agent is expected to increase. The first generation of these peptides (TDM-621) is currently used as a hemostatic agent in Europe. However, TDM-621 exhibits slow gel-formation and low retention capabilities on tissue surfaces. The second generation (TDM-623) was therefore developed to encourage faster gel-formation and better tissue-sealing capabilities, and we subsequently verified its usefulness and increased performance relative to TDM-621 in preclinical open surgery.

Aim: The aim of this study was to verify the efficacy of TDM-623 in terms of its hemostatic effect in endoscopic surgery.

Materials and methods: Evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight female (35 kg) pigs in spine position. Following systemic heparinization, we established a bleeding model by utilizing flexible endoscopic grasping forceps on the anterior wall of the stomach and duodenum. In the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and 1 mL TDM-623 was applied to the wound. After TDM-623 gelation, the endoscope was removed, and the acute hemostatic effect (after 2 min) was confirmed. Histologic evaluation was subsequently performed on resected specimens.

Results: In the endoscopic bleeding model, 17 of the 23 cases (73.9%) showed complete hemostatic effects on the anterior wall of the stomach, whereas on the anterior wall of the duodenum, 18 of 20 cases (80%) showed complete hemostatic effects. Moreover, none of the gels were displaced from the anterior walls of the stomach and duodenum, and histologic evaluation confirmed no infiltration of inflammatory cells.

Conclusion: The new self-assembling peptide (TDM-623) displayed improved hemostatic effects relative to the previous generation (TDM-621) in endoscopic surgery. TDM-623 had potential usefulness for upper gastrointestinal bleeding. Our future work will assess its usefulness for laparoscopic surgery.



S. Molfino 1, M.S. Alfano1, S. Benedicenti1, B. Molteni1, M. Botticini2, N. Portolani1, G.L. Baiocchi1 1Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, BRESCIA, Italy; 2IGIER, Bocconi University, MILANO, Italy

Objective: Indocyanine green (ICG) is a dye used in medicine since the mid-1950 s for different applications in ophthalmology, cardiology and hepatobiliary surgery; thanks to its selective hepatic uptake and biliary excretion, it can be used to evaluate hepatic function in patients scheduled for hepatic resection surgery. The aim of this study is to evaluate the efficacy and the feasibility of ICG guided surgery in the intra-operative localization of liver tumors, comparing the pre-operative radiological aspect, the intra-operative visualization and the post-operative histopathological features of the tumors.

Materials and methods: ICG was intravenously injected for a routine liver function test (LiMON®) in 58 patients who underwent hepatic resection surgery for primitive and secondary liver tumors in the period between November 2016 and September 2018. For each patient was performed an intraoperative visualization of the stain both in vivo and ex vivo, using a near-infrared imaging system. All the images were recorded.

Results: A correct differentiation between liver parenchyma and tumor area was obtained in 89.1% of cases. Five patients were not evaluable due to widespread uptake or complete absence of uptake; it was probably the first cases enrolled in the study for which we were not able to set doses and timing of administration of ICG. In patients in which the method had been feasible, we observed a prevalence of nodular pattern in patients with hepatocellular carcinoma (63%) and a predominance of rim pattern in both cholangiocarcinoma (80%) and metastasis (83%). Furthermore, in patients with HCCs well-intermediate differentiated (G1–G2) was found predominantly a nodular pattern (82.9%), whereas in poorly differentiated ones was prevalent a rim appearance (60%). Regarding radiological correlations, the only one patient who presented an atypical radiological feature in pre-operative evaluation, showed a lesion with no ICG captation in intra-operative visualization.

Conclusions: ICG fluorescence imaging is a safe, minimally invasive and quite inexpensive method, that can be easily administered for routine evaluation of pre-operative liver function. It can be a useful support tool in the intra-operative detection of liver tumors, especially in laparoscopic surgery where it is not possible to directly touch the tissue.



S.H. Choi 1, D.H. Han2, J.H. Lee3, G.H. Choi2, Y.R. Choi4, J.H. Lee5 1Surgery, Bundang CHA Medical Center, SEONGNAM-SI, Korea; 2Surgery, Severance Hospital, SEOUL, Korea; 3Surgery, NHIMC Ilsan Hospital, ILSAN, Korea; 4Surgery, Seoul National University Bundang Hospital, SEONGNAM, Korea; 5Surgery, Asan Medical Center, SEOUL, Korea

Backgrounds & aims: Robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. However, robotic liver resection had not generalized, so far. Thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by prospective multicenter study.

Methods: From July2017 to December 2018, five surgeons who were novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed 46 cases of robotic major anatomical liver resection. Perioperative patient’s clinical data and surgical data were prospectively collected.

Results: 22 cases of left hemihepatectomy, 1 case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, 2 cases of right anterior sectionectomy, 6 cases of right posterior sectionectomy, and one cases of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma for 21 cases following intrahepatic cholangiocellular carcinomas for 7 cases, liver metastases for 3 cases, sarcoma for 1 case, intraductal papillary neoplasms for 2 cases, mucinous cystic neoplasm for 1 case, hemangioma for 1 case, and intrahepatic duct stones for 10 cases. Surgical resection margins for all tumor cases were negative. Total average operation time was 378.58 ± 124.31 (190–696) min and estimated intraoperative blood loss was 276.67 ± 397.41 mL (minimal to 2600 mL). In terms of severe surgical complication, there were 3 cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous trans-hepatic biliary drainage. Only one case out of 46 cases was converted to the conventional open left hemihepatectomy because of bleeding.

Conclusions: In this study, robotic anatomic major liver resection might be safely performed even by robotic beginners but advanced open and laparoscopic liver surgeons.



C. Gonzalez De Pedro, J. Tinoco Gonzalez, L. Tallon Aguilar, E. Perea Del Pozo, V. Duran Muñoz-Cruzado, A. Sanchez Arteaga, I. Ramallo Solis, F. Pareja Ciuro, J. Padillo Ruiz Cirugia General, Hospital Virgen Del Rocio, SEVILLA, Spain

Objective: To present the systematization of the developed technique for video-assisted retroperitoneal access for pancreatic necrosectomy once the previous approaches according to the step-up approach have been exhausted.

Methods: Descriptive study of a cohort of 6 patients subjected to videoretroperitoneoscopy (VR) of 2016–2018. We realized a comparative study with the historical series of 20 open necrosectomies (ON) from 2011 to 2017. We analyzed hospital stay, number of interventions required and complications according to Clavien-Dindo.

Surgical technique: With the patient at 30° on right lateral decubitus, access is gained through the path of the percutaneous drainage catheter after opening of the aponeuroses of the oblique and transverse muscles of the abdomen. A 15 mm laparoscopic trocar is inserted and a cavity is created with pneumoretroperitoneum at 15 mmHg. It is accessed with an optic of 0° and 5 mm, and the work space is extended with aspiration and hydrodissection. With 5 mm grippers, the necrotic material is removed, washed and drained. A two light silicone probe is left, one light for drainage and another one for washing.

Results: The mean age was 52.2 ± 8.1 for VR and 60.2 ± 15.4 years for ON (p = 0.23), the median stay 34 (28–60) vs. 38 (23–58) days, p = 0.497, the median number of reoperations was 1 (1–2) vs. 2.5 (1–3) p = 0.02, and median complications according to the Clavien-Dindo grade of 2 (1.75–4) vs. 4 (2–5) p = 0.01. They required ICU 2 (33%) VR vs 17 (85%) ON (p = 0.01). The death rate was 0% in VR vs 20% in ON.

Conclusions: The described technique provides a minimum invasion to the patient, allowing a necrosectomy under endoscopic vision, with an improvement of the results in terms of complications, at the expense of a median hospital stay of one month.



R. Caruso, E. Vicente, Y. Quijano, H. Duran, B. Ielpo, I. Fabra, E. Diaz, L. Malave, R. Isernia, E. Pinna, V. Ferri General Surgery, Sanchinarro University Hospital, MADRID, Spain

Background: Minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. In fact, the indication for robotic surgery in pancreatic disease has been controversial. The present study aimed to assess the safety and feasibility of robotic pancreatic resection.

Methods: We retrospectively reviewed our experience of robotic pancreatic resection done in Sanchinarro University Hospital. Clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed.

Results: From October 2010 to September 2018, 71 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 62 patients, 40 were male and 31 female. The average age of all patients was 63 years. Operative time was 340 min. Among the procedures performed were 21 pancreaticoduodenectomies (PD), 33 distal pancreatectomies (DP), 17 tumor enucleations (TE). The mean hospital stay was 16.6 days in PD group, 8 days in DP group and 8.2 days in TE group. Pancreatic fistula occurred in 13 cases (20%), 3 after PD, 4 after DP, and 6 after TE. Four patients had postoperative transfusion in PD group and one in DP group. Conversion to open laparotomy occurred in four patients (8%). No serious intraoperative complications were observed.

Conclusions: From our early experience, robotic pancreatic surgery is a safe and feasible procedure. Further experience and follow-up are required to confirm the role of robotic approach in pancreatic surgery.



Y. Liu 1, B. Guo1, S. Prasad2 1College of Engineering, Mathematics and Physical Sciences, University of Exeter, EXETER, United Kingdom; 2Endoscopy Department, The Royal Devon and Exeter NHS Foundation Trust, EXETER, United Kingdom

Aim: This work aims to study the contact pressure between the moving capsule and a synthetic small intestine in order to provide design guidance for prototyping the self-propelled capsule robot for small-bowel endoscopy.

Method: Since small-bowel peristalsis consists of peristaltic contraction and wave distension, the contacts between the capsule and the small intestine are multimodal. We consider three contact cases for the capsule robot. Case 1: the capsule moves on a flat small intestinal surface; Case 2: the capsule moves in a collapsed intestine with a flat surface support; and Case 3: the capsule moves in a surrounded small intestine. By considering these three contact cases, experimental testing and finite element analysis (FEA) were conducted by measuring the contact pressure between the small intestine and the capsule.

Results: (1) The average contact pressure for Case 1 is P1 = 0.8140 [kPa]; (2) the contact pressure for Case 2, P2 = 2.1759 [kPa], is larger than that of Case 1; (3) the pressure due to hoop stress, Ph = 11.5886 [kPa], dominates the contact pressure of Case 3, P3 = 14.1400 [kPa]. Therefore, the FEA result, P2 + Ph, fits the experimental result in Case 3 with a high accordance.

Conclusion: Our experimental and numerical results show a high accordance, demonstrating the validity of the approach which can be used for shape optimisation and actuator design of the robot.



H.F. Fuchs, R.R. Datta, R. Wahba, G. Dieplinger, F. Gebauer, C.J. Bruns, D. Stippel Surgery, University of Cologne, COLOGNE, Germany

Introduction: Minimally invasive single port surgery was associated with large incisions up to 2–3 cm, complicated handling due to the lack of triangulation, and instrument crossing.

Aim of this prospective study was to perform true singleport surgery (cholecystectomy) without the use of assisting trocars using a new surgical platform that allows for triangulation incorporating robotic features and to measure the perioperative outcome and cosmetic results.

Methods and procedures: The new technology has been introduced to our academic center as first European site after FDA and CE clearance. In patients with cholecystitis and cholecystolithiasis, the operation is performed through only one 15 mm trocar. For patients safety, intraoperative cholangiography using intravenous ICG and a standard Stryker 1588 5 mm camera was performed.

Results: Symphonx was used in n = 11 patients for abdominal surgery (4 females, median age 45.2 [32–77], median BMI 32.7 [29–35]. A total of 5 patients underwent surgery using no additional than the 15 mm trocar; in the remaining patients, one assisting instrument (3–5 mm) was used. Mean OR time was 103.6 [63–122] min. The postoperative course was uneventful in 10 patients, one patient required postoperative interventional drainage of a bilioma 1 month postoperatively. The cosmetic result was excellent. No intraoperative complications occurred.

Conclusion: This is the first human case series using the SymphonX platform for abdominal surgery without assisting instruments.

Laparoscopic cholecystectomy in patients with cholecystitis and cholecystolithiasis using the symphonx platform through only one 15 mm trocar is feasible and safe. The cosmetic result is promising. Further recruiting of patients for validation of the new technology is necessary and ongoing.



A. Szold, A. Ben Yehuda TEL AVIV, Israel

Introduction: Traditional laparoscopic instruments have limited degrees of freedom and are not ergonomic. This results in severe limitations in performing complex, and even simple tasks in surgery, limiting many surgeons from performing a variety of minimally invasive procedures.

HandX™ is a hand-held, electromechanical smart instrument with robot-like features. The instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. The instrument is 5.5 mm in diameter, lightweight, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. After the regulatory process was completed we have tested the device clinically through a structured, approved, clinical trial.

Materials and methods: After IRB approval 30 patients were recruited to the trial. We have included a variety of procedures that require suturing and complex tissue manipulation. Two experiences surgeons performed all procedures. After completing each procedure the surgeons completed a detailed standard usability (SUS) questionnaire.

Results: 30 procedures were completed successfully without complications or device malfunction. There were 15 female and 15 male patients with an average BMI of 27. Procedures performed were 6 right hemicolectomis with intra-corporeal anastomosis, 3 paraesophageal hernia repairs and fundoplication, 3 diagnostic laparoscopies, 2 TAPP procedures, 10 ventral hernias with fascial suturing, and 6 laparoscopic cholecystectomies. The average performance score was 84.70/100.

Conclusions: The results suggest that the HandX device is safe and easy to use and may offer a simple solution for enhancing minimal invasive surgery capabilities and possibly reduce conversion rates while maintaining current standard surgery flow.The HandX could potentially extend the surgeon’s abilities to access hard to reach anatomy and perform complex maneuvers and present a cost-effective alternative to large console-based robotic systems.



Q. Shi, Y.S. Zhong, P.H. Zhou Endoscopy Center, Zhongshan hospital, SHANGHAI, China

Objective: Endoscopic submucosal dissection (ESD) has become widely accepted treatment for rectum neuroendocrine neoplasm. The aim of this study is to evaluate the safety and efficacy of ESD with dental floss-assisted suspension traction for rectal neuroendocrine neoplasm.

Methods: We retrospectively reviewed the medical records of the patients, who underwent ESD for rectum neuroendocrine neoplasm at Endoscopy Center of Zhongshan Hospital, Fudan University. The data of operation time, R0 resection and adverse events were collected analyzed.In DFS-ESD group: after the mucosa was partly incised along the marker dots, the next step was to construct traction device, similar to others in ESD, with dental floss and hemoclip. The dental floss was tied to any arm of the metallic clip. The hemoclip was attached onto the incised mucosa, another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. The submucosa was clearly exposed with the traction of dental floss and the resection could proceed.

Results: 37 patients were enrolled in the study. There were 17 patients treated by ESD with dental floss-assisted suspension traction and 20 patients treated by conventional ESD. The average tumor size was (0.74 ± 0.2)cm in both group. The operation time was 17.9 ± 6.6 min in conventional ESD group and (14.7 ± 3.3) min in DFS-ESD group (t = 1.776, P = 0.084). According to pathological grading about rectal neuroendocrine neoplasm, there were 17 grade 1 (G1) and 3 grade 2 (G2) in conventional ESD group while 13 grade 1 (G1) and 4 grade 2 (G2) in DFS-ESD group (?2 = 0.436, P = 0.509). Among 37 cases in this study, all the basal resection margins were negative, the en blot resection rate was 100% and the curative resection rate was 100%. However, pathological results showed tumor tissue close to the burning margin in 5 cases of conventional ESD group and in 2 cases of DFS-ESD group (?2 = 0.364, P = 0.546).

Conclusions: ESD with dental floss-assisted suspension traction for rectum neuroendocrine neoplasm can assist exposing tumor borders, provide good vision during the procedure and offer clearer anatomic structure, so as to simplify operation, reduce operation time and ensure the negative basal margin. It is especially suitable to be promoted in primary hospitals.



J.A. Luzon 1, B.V. Stimec2, R. Kumar3, O.J. Elle3, B. Edwin3, D. Ignjatovic1 1Department of Digestive Surgery, Akershus University Hospital, AKERSHUS, Norway; 2Anatomy Sector, Department of Cell Physiology and Metabolism, Faculty of Medicine, University of Geneva, GENEVA, Switzerland; 3The Intervention Centre, Oslo University Hospital, Rikshospitalet, OSLO, Norway

Aims: 3D reconstruction of patient-specific anatomy influences preoperative planning and surgeon performance. Though semi-automated applications facilitating fast reconstruction are described in the literature, quality assessment of CT-derived models from a clinician/surgeon’s perspective is missing. The aim of this article is to compare semi-automated and manual 3D reconstructed central mesenteric vascular models quantitatively and qualitatively.

Methods: Pre-operative CT-datasets of 24 patients included in the clinical trial ‘Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic MDCT Angiography’ were reanalyzed. Manual reconstruction was through Mimics medical image processing software while semi-automatic was through a multistep algorithm with vessel-enhancement followed by active-contour segmentation. CT-datasets were delivered for semi-automatic segmentation in 4 batches (6 patients each). Manual segmented models were the reference group. Batches 1–3 contained datasets with usual anatomy while Batch 4 consisted of datasets with unusual anatomy. Feedback was provided after each batch reconstruction. Completeness of semi-automated reconstructed models was assessed quantitatively (root mean square [RMS]) with 3D image processing software CloudCompare and qualitatively (visual evaluation missing vessels) to the corresponding reference models. Vessels assessed were those of interest to the surgeon performing right colectomy.

Results: 48 models from 24 patients (13 females, age 44–77) were compared. Quantitatively, batch one: mean RMS 0.74 + SD0.22, two: 0.54 ± SD0.14, three: 0.51 ± SD0.12, four: 1.20 ± SD0.82, overall: 0.73 ± SD0.49 mm. Qualitatively, only 2(8.3%) semi-automated models presented all vessels. Missing: right colic: 7/8 (87.5%, caliber 0.21 ± SD0.05 cm), whole vessel missing 4/8 (50%, 0.21 ± SD0.64), partial 3/8 (37.5%, 0.19 ± SD0.29); middle colic: 18/24 models (75%, 0.28 ± SD0.05), whole 7/24 (29.2%, 0.25 + SD0.03), partial 11/24 (45.8%, 0.27 + SD0.07); ileocolic: 10/24 (41.7%, caliber 0.335 ± SD0.06), whole 1/24 (4.2%, 0.37), partial 9/24 (37.5%, 0.32 ± SD0.06 cm). Unusual anatomy: missing in 5/6 (83.4%) models, 1/9 (11.1%) anomalies detected (accessory middle colic arteries, Tandler-Buhler anastomoses, multiple middle colic veins and pancreaticoduodenal vein). Detected vessel calibers were significantly higher than in the missing vessels (middle colic p = 0.000, right colic p = 0.016, ileocolic p = 0.000). Vessel fusion was detected in 16/24 (66.7%) models.

Conclusion: Despite acceptable results of the quantitative analysis, results of the qualitative comparison indicate that semi-automatic generated central mesenteric vascular 3D-models, if used as roadmaps, could cause considerable confusion at surgery due to missing and/or fused vessels.



S.F. Hardon 1, L. van Gastel1, T. Horeman2, H.J. Bonjer1, F. Daams1, D.L. van der Peet1 1Surgery, VU Medisch Centrum, AMSTERDAM, The Netherlands; 2BioMechanical Engineering, Delft University of Technology, DELFT, The Netherlands

Aims: Force feedback and assessment provides detailed insight into tissue manipulation skills. The aim of this study is to evaluate learning curves for basic laparoscopic skills based of force and motion learning curve patterns. Morevover, we aimed to detect the favourable time span for this curriculum for each individual trainee.

Methods: In this prospective cohort study, first year surgical residents participated in a three week at home training course. A mobile box training was equipped with Forcesense system for objective force, motion and time based assessment. The system provides seventeen unique metrics. The training goal was set by the mean score of proficient laparoscopic surgeons. Each repetition was captured and made available for analyses. Continuous force feedback was provided during training. Curve fitting was used to estimate the learning curve plateau and the number of repetitions needed to approach the plateau phase and to reach proficiency level. Finally, a comparisson between novices and experts was executed.

Results: A total of 2007 attempts, executed by 20 residents were captured and analyzed. Significant improvement of motion analysis parameters (e.g. path length and time) was observed for all training tasks, except for the fifth tasks. Tissue manipulation skills (i.e. maximum and mean applied force) significantly improved by training tasks 2, 3 and 6. Learning curve analysis revealed various shapes and lengths of the individual learning curves. A large range in learning curve plateaus was found between trainees and between tasks. Each trainee managed to accomplish the preset goals within three weeks.

Conclusion: Force- and motion based assessment provides insight into both tissue manipulation and instrument handling skills. When combined in learning curve analysis, these parameters effectively show progression towards proficiency for each individual trainee over time. We emphasize the variation in learning curves between trainees. Therefore, we recommend individually tailored courses provided with objective force- and motion-based learning curve tracking.



A. Phaily 1, A. Ali2, J. Thomas3 1Department of Surgery, Imperial College London, LONDON, United Kingdom; 2Department of Surgery, Royal National Orthopaedic Hospital, LONDON, United Kingdom; 3Department of Surgery, University Hospital of Wales, CARDIFF, United Kingdom

Aims: Novel technologies and scientific research have changed the nature of modern surgery and have resulted in the increasing use of minimally invasive surgery (MIS). Continued innovation in the fields of robotics, optics, miniaturisation, computing and developments in artificial intelligence hold promise that MIS will result in a paradigm shift in the future of surgery. This article assesses the role of MIS and its application in trauma, with a specific focus on laparoscopic surgery.

Methods: A literature search of the PubMed/MEDLINE, Cochrane Library, Web of Science and National Institute for Health and Care Excellence Evidence databases using entry sets of Medical Subject Headings (MeSH) for Abdomen (or Abdominal), Trauma and Laparoscopy (or Laparoscopic) as well as a comparative search of the grey literature was also carried out, as well as specific searches of Google Scholar for articles not available via the main databases

Results: 2623 unique articles were screened. Following abstract review, 64 articles were selected for further analysis. Full text analysis of the 65 eligible articles resulted in selection of 4 systematic reviews for inclusion in the analysis. Results show laparoscopy in abdominal trauma is associated with fewer complications, reduced hospital length of stay, less morbidity and a reduction in negative laparotomy rates in haemodynamically stable patients. Current systematic reviews are based on low quality studies with a great degree of heterogeneity. Alternative MIS methods such as endoscopy and angioembolisation have been successfully used as adjunct during non-operative management of abdominal trauma patients.

Conclusion: To increase preparedness for the inevitable rise in the worldwide trauma burden, a concerted effort must be made to focus research efforts on multi-centre, prospective studies on MIS in order to produce meaningful guidelines. Hybrid non-operative and minimally invasive techniques will have a greater role to play in future trauma management. Application of current and future technological innovations dedicated training in MIS and increased research efforts are still needed if we are to effectively combat the individual, societal and global burden of trauma.



J. van den Bos 1, R.M. Schols2, S. van Kuijk3, F. Wieringa1, L.P.S. Stassen1 1Surgery, Maastricht University Medical Center, MAASTRICHT, The Netherlands; 2Plastic and reconstructive surgery, Maastricht University Medical Center, MAASTRICHT, The Netherlands; 3Clinical epidemiology and Health technology assessment, Maastricht University Medical Center, MAASTRICHT, The Netherlands

Aims: Investigate whether different calculation methods to express fluorescence intensity as target-to background ratio, described in current literature, are comparable and which method(s) match human perception.

Methods: Comparison of 3 calculation methods from current literature (Osirix, ImageJ and Photoshop) to measure fluorescence intensity during laparoscopic cholecystectomy measured at the exact same locations within recorded images of two categories: ex-vivo fluorescence imaging and in-vivo fluorescence imaging during laparoscopic cholecystectomy. Currently applied formulas to present fluorescence intensity (FI) in relation to the background (BG) signal are compared with the subjective assessment by the human observers. These three formulas are ‘Signal contrast = (FI in fluorescence regions—FI in BG) / 255’, ‘Target-to-background ratio = (FI of target—FI of BG) / FI of BG’, ‘Signal-to-background ratio = FI of Cystic duct / FI of liver’ and ‘Target-to-background ratio = (FI of Target—Noise) / (FI of BG—Noise)’.

Results: In our evaluation Osirix and ImageJ gave similar results, while Osirix values were always lower compared to ImageJ. Values obtained via Photoshop however are less evidently related to those obtained with Osirix and ImageJ. The formula Target-to-background ratio = (FI of Target—Noise) / (FI of BG—Noise)was less corresponding with human perception compared to other used formulas.

Conclusions: Fluorescent intensity measurement results from the programs Osirix and ImageJ are similar, allowing for comparison of results between these programs. Results using Photoshop differ from these, making direct comparison not possible. This is important when interpreting study results. We propose to report both target and background fluorescence intensity in manuscripts, so that calculations between articles can be made.



V.V. Grubnik 1, V.V. Ilyashenko2, R.S. Parfentiev2, O.S. Burlak2, V.V. Grubnyk2 1Department of surgery, Odessa medical university, ODESSA, Ukraine; 2Department of Surgery #1, Odessa medical university, ODESSA, Ukraine

Aim of the study was to compare results of laparoscopic transabdominal (LA) and posterior retroperitoneoscopic (RA) adrenalectomy.

Methods: From 2013 to 2017 years 86 patients with adrenal tumors were randomized in two groups: 44 patients with LA (group I), and 42 patients with RA (group II). Both groups were comparable with regard to demographic and clinical parameters, comorbidities, and size of tumors. Laparoscopic transabdominal adrenalectomy was performed employing the Gagner’s technique. Retroperitoneoscopic adrenalectomy was performed using the Walz’s technique.

Results: There were no serious complications and mortality in both groups. Conversions were done in 4 cases (9.0%) in group I, and in 1 case (2.3%) in group II due to size of tumors and technical difficulties. Operative time, time to first intake, analgesic requirements, length of hospital stay, postoperative complications were all significantly lower in the RA group.

Conlusions: RA provides better perioperative outcomes compare to LA. RA is the preferred operation for not large adrenal tumors.



D. Saavedra-Perez 1, O. Vidal1, J.M. Martos2, A. de la Quintana3, J.I. Rodriguez4, J. Villar5, J. Ortega6, A. Moral7, M. Duran8, M. Valentini1, L. Fernandez-Cruz1 1Endocrine Surgery, Hospital Clinic of Barcelona, BARCELONA, Spain; 2Endocrine Surgery, Hospital Universitario Virgen del Rocio, SEVILLA, Spain; 3General and Digestive Surgery, Hospital Universitario Cruces, BIZKAIA, Spain; 4Endocrine Surgery, Hospital Universitari Josep Trueta, GIRONA, Spain; 5Endocrine Surgery, Hospital Universitario Virgen de las Nieves, GRANADA, Spain; 6Endocrine Surgery, Hospital Clínico Universitario, VALENCIA, Spain; 7General and Digestive Surgery, Hospital Universitario de la Santa Creu i Sant Pau, BARCELONA, Spain; 8General and Digestive Surgery, Hospital Universitario Rey Juan Carlos, MADRID, Spain

Aims: Laparoscopic adrenalectomy has become the standard of care for treating adrenal tumors. Conversion from laparoscopic adrenalectomy to an open approach during surgery may be necessary in some cases. This study aimed to identify risk factors for open conversion of laparoscopic adrenalectomy.

Methods: Retrospective analysis of all consecutive patients undergoing lateral transperitoneal laparoscopic adrenalectomy in six endocrine surgery units of the Spanish Adrenal Surgery Group (SASG) between January 2005 and December 2017. Demographic, clinical, surgical and histopathologic characteristics were recorded. Risk factors for conversion were assessed by logistic regression analysis.

Results: Of a total of 865 patients included in the study, 58 (6.7%) required conversion to open surgery. In the univariate analysis, factors associated with open conversion from laparoscopic to open adrenalectomy were body mass index (BMI) > 30 kg/m2 (p = 0.002), previous abdominal surgery (p = 0.015), tumor size > 5 cm (p = 0.001) and surgery for pheochromocytome (p = 0.034). In the multivariate analysis, independent risk factors were BMI > 30 kg/m2 (odds ratio [OR] 4.26, 95% confidence interval [CI] 2.81—8.75; p = 0.001), tumor size > 5 cm (OR 1.015, 95% CI 4.24—28.31; p < 0.001 = and surgery for pheochromocytoma (OR 2.96, 95% CI 1.89—11.55; p = 0.015).

Conclusions: Obesity, tumor size, and pheochromocytoma as the type of adrenal tumor were predictive factors for introperative conversion from laparoscopic to open adrenalectomy. Preoperative assessement of these characteristics should be valuable to clinicians in discussing conversion risk with patients and for surgical planning.



B. Seeliger 1, M.K. Walz2, P.F. Alesina2, V. Agnus1, M. Barberio1, A. Saadi3, M. Worreth3, D. Mutter1, J. Marescaux1, M. Diana1 1Institute of Image-Guided Surgery, IHU-Strasbourg, STRASBOURG, France; 2Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, ESSEN, Germany; 3Department of Surgery, Neuchâtel Hospital, NEUCHÂTEL, Switzerland

Aims: The posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation.The aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and perfusion assessment in the posterior retroperitoneoscopic approach.

Methods: Six pigs underwent synchronous (n = 5) or sequential (n = 1) bilateral posterior retroperitoneoscopic adrenalectomy (PRA, n = 12). Fluorescence imaging was obtained via intravenous administration of 3 mL of Indocyanine Green (ICG) using two near-infrared camera systems. Fluorescence-based visualization of adrenal glands before vascular division (n = 4), after main vascular pedicle ligation (negative control, n = 1) or after adrenal division (n = 7) was followed by completion adrenalectomy. One of the animals had undergone ICG injection 3 h previously, during another study. The dynamic evolution of fluorescence signal intensity over time was recorded and analyzed using a proprietary software. The computed color-coded perfusion cartography was superimposed onto real-time images obtained by corresponding left (L) and right (R) camera systems. The slope of fluorescence signal intensity evolution over time in the regions of interest (ROI) served to assess adrenal perfusion by means of quantitative fluorescence signal analysis.

Results: In the retroperitoneum, the adrenal glands were promptly highlighted after primary intravenous ICG administration or showed an increase in fluorescence signal intensity upon reinjection (both glands in a recovery pig and one gland in the sequential approach). After left adrenal main vascular pedicle ligation, the gland displayed low perfusion (blue; ROIs A1-A2 in Figure 1), while a weak fluorescence signal after completion adrenalectomy suggests perfusion via collateral vessels. With intact vascular supply, the caudal segment of the right adrenal (A3) gland showed a significantly higher perfusion rate (red) than the ischemic cranial segment (A4). Quantitative analysis of logarithmic fluorescence intensity showed a statistically significant difference between perfused and ischemic zones (p = 0.005) allowing to assess gland vascularity. Kidneys (K) and adrenal glands showed distinct perfusion curves (Figure 1).

Conclusions: Prior to dissection, fluorescence imaging allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. During adrenal gland surgery, ICG injection complemented by a computer-assisted quantitative analysis helps to distinguish between well-perfused and low-perfused segments.



A. Giordano, G. Alemanno, C. Bergamini, P. Prosperi, V. Iacopini, A. Dibella, A. Valeri Sod Chirurgia d’urgenza, AOU CAREGGI, FIRENZE, Italy

Objectives: Giant adrenal tumors are tumors with size more than 6 cm. These are rare cancer associated with malignancy in 25% of cases. The size of these tumors is an important topic in literature because of their higher probability of malignancy and possible technical limitations of laparoscopic approach. We report our center’s experience on laparoscopic adrenalectomy.

Materials and methods: In the last ten years we performed about 242 adrenalectomies for benign and malignant adrenal tumors. 45 of these were giant tumors. The medium size was 9.9 cm (7–22 cm). 23 tumors were on the left adrenal gland and 22 on the right. There were 20 women and 25 men, the average age was 55 (21–81 years). 29 of these cancers were laparoscopically removed and 16 with open approach. 2 cases of open conversion.

Results: Betweenn the 29 tumors laparoscopically removed we recorded 6 cases of carcinoma, 2 endothelial cysts, 6 adenomas (3 with aldosterone and 2 with cortisol hypersecretion), 2 myelolipomas, 10 pheochromocytomas and 3 metastases from lung carcinoma. The surgical outcomes in these patients were optimal in terms of good pain control and hospital stay (median 3 days). The average time of the intervention was 110 min with very low blood less (90 ml). No postoperative complications were recorded. The removal of the adrenal gland necessitated 3 or 4 trocars. in the dissection and resection phases we always used radiofrequency scalpel. The follow up after 12 and 24 months didn’t show local recurrences.

Conclusions: Laparoscopic adrenalectomy offers significant advantages over the open approach. The size of these tumors is still at the center of debate for the choice of the technique. The tumor size is only a predictive parameter of possible malignancy. The laparoscopic approach is a safe and feasible method in terms of surgical and oncological outcomes also for the giant adrenal tumors, only if performed by expert surgeons and in high-volume centers. Vascular or adjacent organs infiltration is a contraindication to the laparoscopic approach.



A. Balla 1, L. Palmieri1, F. Meoli1, D. Corallino1, M. Ortenzi2, P. Ursi1, M. Guerrieri2, S. Quaresima1, A. Paganini1 1Department of General Surgery and Surgical Specialties, Paride Stefanini, Sapienza University of Rome, ROMA, Italy; 2Department of General Surgery, Università Politecnica delle Marche, ANCONA, Italy

Aims: Adrenal gland size greater than 6 cm is considered a contraindication to laparoscopic adrenalectomy (LA). Aim of the present case-control study is to compare the surgical outcomes in patients undergoing LA for adrenal gland measuring = 6 cm versus = 5.9 cm in diameter.

Methods: From January 1994 to August 2018, 552 LAs were performed in the two authors’ centers which follow an identical treatment protocol. Eighty-one patients with an adrenal gland size = 6 cm (intervention group) were included in the study. Based on Body Mass Index (BMI) class (18–24.9, 25–29.9, 30–34.9, 35–39.9, > 40 Kg/m2), lesion side (right or left), surgical technique (anterior transperitoneal for right and left-sided lesions, anterior transperitoneal submesocolic for left-sided lesions) and lesion type (Conn-Cushing, pheocromocytoma, primary adrenal cancer or metastases, other type of lesion), 81 patients with an adrenal gland lesion measuring = 5.9 cm in diameter were included (control group) and paired to the intervention group.

Results: Comparing the intervention and control groups, statistically significant differences were observed in mean lesion size (3.305 ± 1.157 and 6.969 ± 1.447, p = < 0.0001) and in mean operative time (85.06 ± 31.67 and 101.42 ± 52.43, p = 0.0174). Four conversions to open surgery were observed in the control group (4.94%) and 8 in the intervention group (9.88%) (p = 0.3690). In the control group, 3 postoperative complications were observed (3.7%) and in the intervention group 5 postoperative complications were observed (6.17%) (p = 0.7196). Postoperative blood transfusions were required in 4 intervention group patients (4.94%) and in none of the control group (p = 0.1204). Mean postoperative hospital stay was 4.12 ± 2.38 in the control group and 4.62 ± 2.46 in the intervention group (p = 0.1957).

Conclusions: The only significant difference between the two groups was the operative time which was longer in the intervention group. Conversion and complication rates were also higher in the intervention group but the difference was not statistically significant. Based on the present data, adrenal gland size measuring more than 6 cm in diameter is not a contraindication to a laparoscopic approach.

O151—SOLID ORGANS—Gynaecology


D.M.T.V. Klemann Gynaecologie, Zuyderland, MAASTRICHT, The Netherlands

Aims: Damage burden incidents have become a serious problem since the introduction of laparoscopic surgery. From 2007 to 2016, the increase of all medical claims in the Netherlands was +4.5%; the damage burden off all incidents increased even 500%. The primary aim of this supplementary study was to analyse absolute and relative numbers and sizes of medical claims after laparoscopic surgery (N = 317 in the period 2008–2017). In order to identify risk factors associated with medical claims related to laparoscopic surgery, we reviewed all claims related to laparoscopic gynaecologic surgery filed from 1993 to 2015.

Methods: Data of medical claims of Centramed and MediRisk were used from 2007 till 2016 (N = 15.335). Both are liability insurers for claims, and assume together 95% of all Dutch hospitals. To identify the claims related to laparoscopic surgery of all medical specialties, we searched the databases. Lapraroscopic related claims could be separately identified in the database of MediRisk. We reviewed the medical and legal charts of all claims related to laparoscopic gynaecologic surgery of both Centramed and MediRisk (N = 328).

Results: Claims related to laparoscopic surgery decreased over a period of 10 years; in 2008 versus 2017, 42 (4%) versus 20 (2%) of all claims were related to laparoscopic surgery. In all medical liability claims concerning laparoscopic surgery, general surgeons were responsible for 217 (68.5%); gynaecologists for 79 (24.9%); and orthopaedics and urologists for the remaining 6.6%.The costs from these claims, differed from 2 to 13% of the total damage burden per year. The review of medical charts of claims related to laparoscopic gynaecologic surgery showed that 82% of claims were filed for visceral and/or vascular injuries (40% bowel injuries, 20% ureter). 38% of the injuries were entry-related. A delay in diagnosing injuries was the primary reason for financial compensation.

Conclusion: Evaluating and learning from complications and claims will improve medical health care. In contrast to overall trends and developments considering medical claims, claims concerning laparoscopic surgery decreased, possible due to a rising learning curve. Considering laparoscopic surgery, extra caution is required at moment of entry and the early recognising complications and at pre-operative counselling from patients.



S. El-Shakhs General Surgery & Surgical Oncology, Menoufia University, AL MINUFYA, Egypt

Aim: This prospective study was conducted to evaluate feasibility & oncological safety in performing laproscopic radical nephrectomy for renal cell carcinoma.

Patients & principle: This prospective study was conducted at Menoufia University Hospital from the period of January 2015 to January 2018 on 22 patient with RCC.

Methods: The patient was positioned either right lateral or left lateral according to the tumour site. We used to do it by 4 ports, 2 × 10 ml for camera & clip applier, other 2 × 5 ml for surgeon left hand & assistant. After exploration of the abdomen by camera, first step is a colon mobilization medially, followed by release of the upper border from liver on right side or spleno-pancreatic block on left side. Then the ureter & gonadal vessels were identified & transected. The attention was directed to the hilum where renal vein is identified followed by renal artery which is posterior. Clipping of the artery first then clipping of renal vein after being collapsed. Finally complete mobilization from the lateral wall, small incision for tumour excision. Drain was left for 24 h. Patient started oral on the same day and discharged 2nd day morning.

Results: 7 patients had left renal tumours & 15 had right. Twenty patients underwent total laparoscopic radical nephrectomy & 2 were converted one for difficulty of mobilizing the fatty colon due to obesity, 2nd for extensive adhesion that obscured the vena cava. No intraoperative blood was given except one & this pt received another 2 units postoperative. Operative time was 175 + 23 min. patient started oral on same day night except those who were converted started on 2nd day post operative. The average number of harvested lymph nodes were 7 + 3 nodes. All were renal cell carcinoma, 17 clear cell, 2 sarcomatoid & last one with chromophobe. The mean tumour size was 9 + 3 cm) & the average was 5–17 cm.

Conclusion: Laparoscopic radical nephrectomy proved to be feasible, safe with a smooth postoperative course.

O153—SOLID ORGANS—Parathyroid


M. Rubio-Manzanares Dorado 1, V. Pino Diaz1, J. Padillo Ruiz2, J.M. Martos Martínez1 1Endocrine Unit, Hospital Virgen Del Rocio, SEVILLA, Spain; 2General Surgery Department, Hospital Virgen Del Rocio, SEVILLA, Spain

Aims: About one and half year ago, we proposed a novel pure endoscopic cervical approach to posterior mediastinum parathyroid adenomas that we called ‘prevertebral cervical approach’.

Methods: Step by step technique is described for both right and left sided adenomas, by means of photographs and short video clips.

Results: From June 2015 to December 2018, 7 patients were operated using this technique. Five adenomas were right sided and 2 were left sided. Mean surgical time was 31 ± 5 min. There were neither intraoperative nor postoperative complications. Four patients presented a slight subcutaneous emphysema which did not cause complaints. All patients were discharged next day after surgery except for one patient with a previous neck open 4 glands removal for secondary hyperparathyroidism, which required calcium replacement. Calcium and parathyroid hormone levels were normalized in the other 6 patients after surgery.

Conclusions: This cervical pure endoscopic approach has shown, in our experience, a high feasibility and short surgical time, with excellent postoperative results regarding to patient comfort, length of stay and disease cure, offering besides a very reasonable procedure cost, and may result in a less aggressive surgical option when compared with thoracic approaches.

O154—SOLID ORGANS—Parathyroid


V. Drakopoulos, N. Roukounakis, S. Voulgaris, V. Lygizos, I. Iliadis, P. Trakosari, A. Bakalis, V. Vougas 1st Department of Surgery and Transplantation Unit, District General Hospital of Athens « Evangelismos » , ATHENS, Greece

Introduction: Intraoperative nerve stimulation and neuromonitoring is a commonly accepted practice during endocrine surgical procedures in the neck. Minimally invasive thyroidectomy and parathyroidectomy and especially video-assisted parathyroidectomy are safely and successfully performed in selected patients with appropriate indications.

Material/Method: We present a video demonstrating our technique in a case of a Minimally Invasive Video-Assisted Parathyroidectomy (MIVAP), with intraoperative recurrent laryngeal nerve stimulation. We demonstrate the necessity of modification of the ordinary technique in order to get a positive identification of the nerve.

Conclusion: A modification of the standard technique of intraoperative nerve stimulation is mandatory during MIVAP.



P.A. Yartsev, M.M. Rogal, O.A. Chernysh General surgery, N.V. Sklifosovsky Emergency Medicine Research Institute, MOSCOW, Russia

The aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations.

Patients and methods: The study involved 112 patients with spleen injury grade III who were admitted in our institute in the years of 2013–2018. The patients were divided on two groups. Laparoscopic splenectomy was performed in 62 patients (group I) and ‘traditional’ splenectomy was carried out in 50 patients (group II). There was no difference in the demographic data and trauma severity between the two groups.Non-invasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations (US), X-ray in multiple views and computed tomography (CT) had been performed before the decision about necessity of an operation was made.

Results: Patients after laparoscopic operations had better recovering conditions compare to patients with the same injury after ‘traditional’ splenectomy. Neither surgery related complications no mortalities were registered in both groups. Laparoscopic splenectomy was more time-consuming operation than ‘traditional’ splenectomy. We suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced.

Conclusion: Laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. The operation is indicated in patients with spleen laceration more than 3 cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (more than 500 mL/h on serial US examinations).



V. Calu, M. Oun, C. Paraianu, A. Miron Department of Surgery, Elias Emergency Hospital, BUCHAREST, Romania

The isolated hydatid disease of the spleen is a quite rare condition, liver and lungs being the most common locations. The treatment requires usually splenectomy, open or laparoscopic. There are few reports in the literature describing a spleen-preserving type of surgery.

We present a case of a female patient, 51 y.o., with a large cystic lesion of the spleen, 11 cm in diameter. Lab tests and CT scan confirmed that is a hydatid cyst. After Albendazole treatment and vaccination the patient was referred to us for surgical treatment. The procedure was performed under general anesthesia and laparoscopic approach was performed with the intention to preserve the spleen. After the cyst was identified and adhesiolysis was done, the area was isolated from the rest of the abdominal cavity with sponges with a betadine solution in order to prevent contamination. A needle aspiration of the cyst allowed the evacuation of 550 ml of purulent content, an indicator of a dead cyst. Betadine solution was injected into the lesion. Laparoscopic excision of the cyst was performed using advanced electrocoagulation devices and the spleen removal was not deemed necessary. Two drainage tubes were placed in the remnant cavity. An abdominal ultrasound was performed in the third postoperative day and no collections were identified. The postoperative outcome was uneventful; the patient was discharged in the 6th postoperative day.

The conclusion is that in selected cases, with the cyst located in the anterior part of the spleen, with proper equipment and experienced laparoscopic teams, the cyst can be successfully treated without splenectomy.



T. Donmez, M.E. Gunes, C.A. Dural, C. Akarsu, N.A. Sahbaz, Y. Kesgin General Surgery, Bakirkoy Dr.Sadi Konuk Training and Research Hospital, ISTANBUL, Turkey

Aim: Intraoperative neuromonitoring(IONM) can aid recurren laryngeal nerve(RLN) identification in thyroid surgery. However, its role in reducing the frequency of RLN injury controversial. The use of neuromuscular blocking agents(NMBD’s) may affect IONM during thyroid surgery. A selective neuromuscular recovery protocol was evaluated in a retrospective clinical trial during thyroid neural monitoring surgery.

Methods: Seventy-five patients with American Society of Anesthesiologists physical class I–II–III status who underwent propofol-remifentanil anesthesia for the surgery of the thyroid gland. Deep neuromuscular block was induced with rocuronium 1.2 mg/kg. In Group1, Forty patients were enrolled for reversal of profound neuromuscular block during thyroid surgery (sugammadex 2 mg/kg, after identification of vagus nerve). In group 2, thirty-five patients were enrolled profound neuromuscular block during thyroid surgery(without reversal of NMBD). TOF-Watch acceleromyograph was recorded in response to adductor pollicis muscle for ulnar nerve stimulation in patients with both groups; recovery was defined as a train-of-four (TOF) ratio = 0.9.To prevent laryngeal nerve injury during the surgical procedures, all patients were neurophysiologically detected using IONM.

Results: The total duration of surgery was higher in group 2 than group 1(63.7 ± 5.6, 82.5 ± 6.1;p < 0.001). The mean time to recovery of the TOF ratio to 0.9 was higher in group 2 than group 1(22.3 ± 2.6, 74.3 ± 5.0; p < 0.001). The mean duration of vagus reverse (v1:3,5milisecond) was higher in group 2 than in group1(21.3 ± 1.7, 42.9 ± 5.1; p < 0.001). No significant difference was found between left and right v1–v2 and r1–r2 values in group 1 following nerve monitoring, whereas in group 2, a significant difference was found between left v1–v2, left r1–r2 and right v1–v2 values(0.19 ± 0.07, 0.32 ± 0.1, p < 0.001; 0.20 ± 0.06, 0.28 ± 0.06 p < 0.001; 0.29 ± 0.06, 0.40 ± 0.08, p < 0.001,respectively).

Conclusion: In the follow-up of nerve monitoring, a safe thyroid surgery can not be mentioned unless the effect of the neuromuscular blockade agent is overtaken. Agents that remove the NMBD’s influence should be used to prevent recurrent nerve injury.



T.J. Liang, C.Y. Tsai, S.I. Liu, I.S. Chen Surgery, Kaohsiung Veterans General Hospital, KAOHSIUNG, Taiwan

Aims: Bilateral Axillo-Breast Approach (BABA) thyroidectomy has superior cosmetic outcome but requires a larger working space for manipulation. There has been concerns about the extensive dissection and its damage to the breast. We present an easy and less traumatic technique to produce operative filed in BABA thyroidectomy

Methods: We developed a ‘single bi-axillary tunneling’ technique for working space creation in BABA thyroidectomy. All operations were performed by a single surgeon in the Kaohsiung Veterans General Hospital. The patient’s data were retrospectively reviewed. Operative time, skin flap complications, and other surgical outcome parameters were recorded.

Results: With our technique, the entire working space creation was typically completed within 20–30 min. There was no infection, skin necrosis, flap perforation, and seroma formation. Only minor and small bruises were detected.

Conclusions: The single bi-axillary tunneling method is an easy technique for operative field production in BABA thyroidectomy. It minimizes skin bruises, improves patient satisfaction and remains time efficient.

O159—UPPER GI—Benign Esophageal disorders


V.V. Grubnik1, V.V. Ilyashenko2, V.V. Grubnyk 2, M.R. Paranyak.2 1Department of surgery, Odessa medical university, ODESSA, Ukraine; 2Department of surgery #1, Odessa medical university, ODESSA, Ukraine

The aim of the study was to compare outcomes of paraesophageal hernias repair (PEHR) with mesh and autologous augmentation with platelet rich plasma (PRP) and without mesh in elderly patients.

Methods: 162 adult patients with large PEH undergoing laparoscopic repair from 2014 to 2018 years of our clinic were included. Patients were divided by age: group A (72patients) = 65 years, group B (90patients)—age 66–87 years. In the I group (84 patients)—we used non-absorbable self-fixating ProGripTM mesh for reinforcement of crura repair, II group (72 patients)—crura repair was done without mesh. In the patients of I group pieces of mesh were infiltrated by 2–4 ml of autologous PRP. We determined type-I, and type-III collagens in patients of A and B groups. PRP was prepared from 20 ml blood of the patient. The groups were evaluated according to the following criteria: dysphagia, patient’s symptomatic outcome judgment according to the GERD-HRQL questionnaire and patient’s satisfaction, hiatal hernia recurrence according to upper endoscopy and barium contrast swallow study.

Results: There were no mortality in the patients of both groups. Mean operative time was not significantly different in both groups. Major morbidities were significantly lower in the younger group when compared to the elderly patients (group B). There were similar operative time and blood loss between the groups. The mean length of hospital stay was shorter in-group A. Median length of follow-up was the same in both groups. Recurrence rate was significantly higher in the patients of II group [recurrence rate in-group I was 3.6%, in II group—16.7% (p < 0.01)] Recurrence rate was the same in younger and elderly groups of patients with mesh repair [group I A—2%, group I B—4% (p > 0.05)]. All groups demonstrated significant improvement in GERD-HRQL score. The quantity of total, type-I, and type-III collagens was significantly lower in the elderly group of patients.

Conclusion: Laparoscopic PEH repair can be done safely and effectively in elderly patients. Mesh reinforcement of crura repair with autologous PRP significantly decrease recurrence rate in elderly patients.

O160—UPPER GI—Esophageal cancer


J.W. Butterworth 1, P.R. Boshier1, S. Mavroveli1, J.V. Reynolds2, G.B. Hanna1 1Cancer and Surgery, Imperial College London, LONDON, United Kingdom; 2Surgery, St. James’s Hospital and Trinity College, DUBLIN, Ireland

Introduction: Oeosphagogastric oncology trials have often lacked robust methods of monitoring and surgical quality assurance (SQA), leading to difficulty in interpretation of trial results. This study aims to assess expert opinion regarding challenges to SQA in oncology trials and potential mitigating strategies.

Method: A purposive international cohort of 71 expert stakeholders with experience in oncology trials were recruited including: 35 surgeons; 17 oncologists; 10 trial methodologists, and; 9 trial managers. Semi-structured interviews were thematically analysed using grounded theory. SPSS was utilised to assess differences between trial stakeholders’ opinions.

Results: 389 emergent themes were identified and 74 consensus themes emerged on qualitative analysis of stakeholder responses. Key consensus challenges to implementation of SQA in oncology trials included: Insufficient resources; limitations of surgical volume in centre selection; differing oncological beliefs and resistance to change adoption; overly prescriptive protocols and standardisation contributing to difficulty in surgeon recruitment; and cultural factors leading to difficulties in providing and receiving feedback. Seminal consensus mitigating strategies to overcome challenges to SQA in oncology trials included: trial centre selection according to case volume (n = 31, 44%); requirement for specific centre attributes for inclusion in trials including specialist centre designation and participation in national audit (n = 29, 41%); consideration for surgeons learning curve in surgeon selection (n = 33, 46%); flexible standardisation of trial operating (n = 22, 31%); operation manual utilisation to aid standardisation of surgical interventions (n = 34, 48%); case monitoring using video (n = 22, 31%) or photographs (n = 11, 16%); direct intraoperative observation by an expert (n = 15, 21%), and; histopathological assessment of resected specimens (n = 10, 14%). Other methods of monitoring surgical quality advocated included: recording post-operative outcomes; lymph node yield; case report forms; and real time data monitoring (n = 32, 45%). Oncologists were significantly more likely to state the importance of standardisation of surgery in oncology trials (p < 0.05), and trial methodologists significantly more likely to advocate consideration of surgeons’ learning curve in surgeon selection (p < 0.05).

Conclusion: Surveying international expert stakeholder opinion revealed a wide variety of perceived challenges across all domains of surgical quality assurance. Proposed mitigating solutions require consensus opinion to formulate a framework to aid design of SQA measures within future oncology trials.

O162—UPPER GI—Esophageal cancer


O. Usenko1, A. Sydiuk1, A. Klimas 1, O. Sydiuk2, G. Savenko1 1Gastrointestinal surgery, O.O. Shalimov National Institute of Surgery and Transplantation, National Academ, KYIV, Ukraine; 2ICU, O.O. Shalimov National Institute of Surgery and Transplantation, National Academ, KYIV, Ukraine

Introduction: Reconstruction after esophagectomy together with the reliability of the esophagus-gastric anastomosis (EGA) constitute some of the most important problems in the surgery of the esophagus, because anastomosis leakage is one of the main reasons of lethal surgery.

Material and methods: The research included 60 patients who anderwent the minimally invasive hybrid Ivor Lewis procedure for malignant tumors of esophagus in Shalimov National Institute of Surgery and Transplantation (1 group comprised 30 patients with mechanical EGA end-to-side; 2 group comprised 30 patients with invaginated mechanical EGA).

The objects for estimation included post-operative mortality as well as the number of post-operative anastomosis complications: the number of EGA leakages in the early post-operative period and the number of post operative strictures in the EGA area three, six and twelve months after the surgery.

All patients underwent a course of neoadjuvant chemo/RT in accordance with NCCN guidelines.

Data processing was done by means of Statistic—licensed application programs for Windows.

Results and discussion: Patients belonging to both groups were comparable according to their age, sex, weight, height and surgery duration.

Research group did not register a single case of EGA leakage while 2 patients in control group (? < 0,05). had the leakage which was stopped by means of ‘Endovac’ system. There were 2 cases of esophagus post-operative strictures which developed 3 months after the surgery in the research group which was less than in the control group which saw 6 cases of strictures of EGA (? < 0,05). 6 months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to 4 cases in the research group and 11 cases in the control group (? < 0,05). There were 5 cases of esophagus post-operative strictures which developed 12 months after the surgery in the research group which was less than in the control group which saw 13 cases of strictures of EGA (? < 0,05). Neither of the groups had any cases of post-operative mortality.

Conclusion: The study found that invaginated mechanical EGA within minimally invasive hybrid Ivor Lewis procedure reduces EGA leakages as well as EGA benign strictures.

O163—UPPER GI—Gastric cancer


C. Huang 1, Q. Chen1, Z. Liu1, Q. Zhong1, C. Zheng1, P. Li1, J. Xie1, J. Wang1, J. Lin1, J. Lu1, L. Cao1, M. Lin1, R. Tu2, Z. Huang1, J. Lin1 1Department of Gastric Surgery, Fujian Medical University Union Hospital, FUZHOU, China; 2Fujian Medical University Union Hospital, Fujian Medical University Union Hospital, FUZHOU, China

Background: Three-dimensional (3D) video systems for laparoscopy provide surgeons with additional information on spatial depth not found in two-dimensional (2D) video systems.

Study Design: This study enrolled 156 spleen-preserving splenic hilar lymphadenectomy (LSPSHL) patients in a randomized controlled trial ( Identifier NCT02327481) at the department of gastric surgery at Fujian Medical University Union Hospital between January 2015 and April 2016. The short-term efficacies were compared between the treatment groups. The unedited videos of 80 LSPSHL (40 procedures each for 3D and 2D) were rated for technical performance using the Generic Error Rating Tool.

Results: All patients in the cohort were successfully treated without conversion to open surgery. The data for 156 LSPSHL patients indicate the estimated blood loss (EBL) (3D vs 2D = 66.3 ± 79.3 vs 99.0 ± 119.7, P = 0.046) was significantly less in the 3D group. The postoperative recovery and complication rates were similar (P > 0.05). There were no patient deaths within 30 days of surgery. Two observers analyzed 80 videos of LSPSHL. The results showed there were fewer grasping-errors made in the 3D group than in the 2D group when dissecting the inferior pole region of spleen (IPRS) (P = 0.016) and the superior pole region of spleen (SPRS) (P = 0.022). Additionally, the inter-rater reliability was high regarding grasping-errors in the IPRS (intraclass correlation coefficient (ICC) 0.92) and the SPRS (ICC 0.83). The ICC for the total number of errors was 0.82. The mean of errors in the 3D group (3D vs 2D = 20.4 ± 4.2 vs 23.3 ± 6.3, P = 0.023) was less than the 2D group.

Conclusions: Compared with 2D LSPSHL, 3D technology reduces EBL and technical errors during splenic hilar dissection.

O164—UPPER GI—Gastric cancer


K.H. Lee, Y.S. Jo, S.H. Min, S.H. Ahn, D.J. Park, H.H. Kim, Y.S. Park Department of surgery, Seoul National Bundang Hospital, SEONGNAM-SI, Korea

Background: Due to the technological advance in resolution and stereoscopic depth, the 3-dimensional (3D) laparoscopic system has been widely used in real surgery. However, there have been few studies to confirm the clinical usefulness of the 3D laparoscopic gastrectomy. This study aimed to compare perioperative outcomes between the 2-dimensional (2D) and 3D laparoscopic gastrectomy for gastric cancer patients.

Method: This was a prospective, randomized controlled, single-center, and superiority trial. Patients with histologically confirmed gastric adenocarcinoma and = cT4a tumor were randomly assigned (1:1) to the 2D or 3D group. The primary endpoint was the operation time. Secondary endpoints included estimated blood loss (EBL), amount of blood transfusion, number of retrieved lymph nodes, postoperative mortality, and open conversion rate.

Results: Between October 20, 2016 and August 8, 2018, 84 patients were randomly assigned to the 2D (44 patients) or 3D (40 patients) group. The operation time was significantly shorter in the 3D group (128.2 ± 4.5 min in 2D vs.106.8 ± 6.0 min in 3D, P = 0.005), so the study was closed on the basis of futility. Especially, the lymph node dissection time of station 6 was significantly shorter in the 3D group (37.3 ± 2.5 min vs. 26.9 ± 1.8 min, P = 0.001). EBL (26.4 ± 3.5 mL vs.19.8 ± 2.9 mL, P = 0.16), and the number of retrieved lymph nodes (61.1 ± 3.6 vs. 62.7 ± 3.0, P = 0.74) were not significantly different between two groups. There was no blood transfusion and mortality in both groups, but one open conversion (due to tumor adhesion to pancreatic body) occurred in the 2D group.

Conclusion: The results of this prospective trial supported that the clinical usefulness and safety of 3D laparoscopic gastrectomy for gastric adenocarcinoma.

O165—UPPER GI—Gastric cancer


C. Huang 1, J. Lu1, B. Xu1, C. Zheng1, P. Li1, J. Xie1, J. Wang1, J. Lin1, Q. Chen1, L. Cao1, M. Lin1, Z. Huang1, R. Tu2, J. Lin1 1Department of Gastric Surgery, Fujian Medical University Union Hospital, FUZHOU, China; 2Fujian Medical University Union Hospital, FUZHOU, China

Background: Previous studies have shown that early recurrence (ER) after radical surgery significantly reduces long-term survival in patients with cancer. Currently, the definition and predictors of ER for patients with gastric cancer (GC) after radical gastrectomy are unclear.

Objective: To establish an evidence-based cutoff to differentiate between ER and late recurrence (LR) and to explore the predictors for ER.

Methods: A total of 419 gastric cancer patients in a clinical trial (NCT02327481) from January 2015 to April 2016 were analyzed. A minimum P-value approach was used to evaluate the optimal cut-off value of recurrence-free survival to divide the patients into ER and LR cohorts based on subsequent prognosis. Potential risk factors for ER were assessed with Cox proportional hazards regression model. We performed decision curve analysis to evaluate the clinical utility of prediction model by calculating its net benefit in varied risk thresholds for screening.

Results: Ultimately, 401 patients were included this study, and the median follow-up time was 29 (3–41) months. The optimal length of recurrence-free survival to distinguish between ER (n = 44) and LR (n = 52) was 12 months. The median post-recurrence survival time of ER group and LR group was 3.5 months and 9.5 months, respectively, p < 0.001. Factors associated with ER included a C-reactive protein-albumin ratio (CAR) = 0.131, stage III and postoperative adjuvant chemotherapy(PAC) > 3 cycles. The decision curve analysis yielded a range of risk thresholds (1–70%) at which the clinical net benefit of the risk model consisting of CAR and TNM stage was larger than that of only TNM stage. Further stratification analysis of phase III patients found for patients with CAR < 0.131, PAC with 1-3 cycles (50.0% vs 17.3%, p = 0.029) or > 3 cycles (50.0% vs 4.2%, p < 0.001) could significantly reduce the risk of ER. However, for patients with BMI = 0.131, only PAC > 3 cycles (54.2% vs 16.0%, p = 0.004) rather than 1-3 cycle (58.3% vs 54.2%, p = 0.824) can benefit them.

Conclusions: A recurrence-free interval of 12 months is the optimal threshold for differentiating between ER and LR. Stage III GC patients with CAR = 0.131 may not benefit from PAC with only 1-3 cycles.

O166—UPPER GI—Gastric cancer


C. Huang, Q. Chen, Q. Zhong, C. Zheng, P. Li, J. Xie, J. Wang, J. Lin, J. Lu, L. Cao Department of Gastric Surgery, Fujian Medical University Union Hospital, FUZHOU, China

Background: Robotic systems recently have been introduced to overcome technical limitations of conventional laparoscopic gastrectomy, especially for complex procedures.[#_ENREF_1] We developed a set of procedural operation steps for robotic spleen-preserving splenic hilar lymphadenectomy, which is difficult and recommended in D2 lymph node (LN) dissection during total gastrectomy [#_ENREF_2].

Methods: The robotic operative procedures of splenic hilar lymphadenectomy using the da Vinci ® Si system were demonstrated in a step-by-step manner, with technical tips for each step, in the video clip. The above procedures were performed on 40 consecutive patients with stage cT2-3 proximal gastric cancer between July 2016 and September 2017. The learning curve was analyzed based on the cumulative sum method (CUSUM).

Results: The mean age and body mass index of patients were 55.3 ± 10.4 years (range 29-78) and 23.0 ± 2.7 kg/m2 (range 15.4-28.4), respectively. All spleen-preserving surgeries were successfully performed without open or laparoscopy conversion. Mean operation time of splenic hilar lymphadenectomy was 20.3 ± 6.4 min (range 13.3-46.3); mean blood loss was 13.7 ± 5.3 ml (range 8.0-40.0). The overall average of 38.8 ± 13.1 LNs (range 19-81) was retrieved, including a mean 3.3 ± 1.4 (range 0-8) splenic hilar area LNs, with a 10% (4/40) metastatic rate. No immediate postoperative mortality was observed. 6 patients (15.0%) experienced a complication after surgery; the operation-related complications consisted of one wound complications, one abdominal infection, and one anastomosis leakage. At a median follow-up of 12 months, one patient had experienced lung metastasis. According to the CUSUM, the cut-off point of splenic hilar LN dissection time and blood loss were 15th and 20th cases, respectively.

Conclusion: Robotic surgery can improve the quality of surgery and promote the D2 LN dissection. This procedure is feasible and simplifies complicated splenic hilar lymphadenectomy.

O167—UPPER GI—Gastric cancer


S.H. Min Department of Surgery, Seoul National University Bundang Hospital, SEUNGNAM-SI, Korea

Background: This study was performed to analyze the safety and feasibility of laparoscopic gastrectomy in stage 4 gastric cancer patients by comparing with open surgery, matched with propensity scoring method and to investigate the role of maximum resection of primary gastric cancer and metastasectomy.

Methods: A total of 547 patients were pathologically proven stage 4 gastric cancer. 152 patients with proper surgery were eligible for analysis. After propensity score matching, a total of 78 patients were assigned to laparoscopy and open group.

Results: There were no significant differences between the laparoscopy and open group except for operation time and estimated blood loss. Complication rate did not show statistical significance. The 5-year survival rate was 18.6% and the median survival was 17.8 months. When compared between laparoscopy and open group, there was no difference between the two groups (23.1% 19.7 months, vs. 21.7% 17.1 months, P = .808). In the multivariate analysis of prognostic factor for overall survival, adjuvant chemotherapy and postoperative complication were independent prognostic factors. With REGATTA inclusion criteria applied to our data, the 5-year survival, 2-year survival and median survival was 27.8%, 55.6%, and 26.8 months (95% CI 36.7—84.0), respectively. The median ratio(MR) of the median survival between surgery plus chemotherapy group in the REGATTA study and our study was 1.874, in favor of our study.

Conclusions: Laparoscopic gastrectomy and metastasectomy in stage 4 gastric cancer patients is safe and feasible in terms of long-term oncologic outcome and complications. Maximum resection of primary gastric cancer and metastasectomy should be tried for better long-term oncologic outcome.

O168—UPPER GI—Gastric cancer


C. Huang, Q. Chen, Q. Zhong, Z. Liu, M. Lin, C. Zheng, P. Li, J. Xie, J. Wang, J. Lin, J. Lu, L. Cao Department of Gastric Surgery, Fujian Medical University Union Hospital, FUZHOU, China

Purpose: To develop nomograms for predicting long-term survival for proximal gastric cancer (GC) patients.

Background: The incidence of proximal GC is increasing, and methods or predicting the long-term survival of proximal GC patients have not been well established.

Methods: Between January 2007 and June 2013, we prospectively collected and retrospectively analyzed the medical records of 746 patients with proximal GC. The data were split 75/25, with one group used for model development and the other group used for validation testing. A Cox regression analysis was used to identify the preoperative and postoperative risk factors for overall survival (OS).

Result: Among the 746 patients examined, the 3- and 5-year OS rates were 66.1% and 58.4%, respectively. For the training set, the preoperative T stage (cT), N stage (cN), CA19-9, tumor size, ASA core, and 3–6-month weight loss were incorporated into the preoperative nomogram for predicting OS. In addition to these variables, LVI and the postoperative tumor size, T stage, N stage, blood transfusions and complications were incorporated into the postoperative nomogram. All the calibration curves for OS probability fitted well. In the training cohort, the preoperative nomogram achieved a C-index of 0.751 [95% confidence interval (CI): 0.732–0.770] in predicting OS and accurately stratified patients into 4 prognostic subgroups (5-year OS rates: 86.8%, 73.0%, 43.72% and 20.9%, P < 0.001). The postoperative nomogram had a C-index of 0.758 in predicting OS and accurately stratified patients into 4 prognostic subgroups (5-year OS rates: 82.6%, 74.3%, 45.9% and 18.9%, P < 0.001).

Conclusions: The nomograms accurately predicted the pre- and postoperative long-term survival of proximal GC patients.

O169—UPPER GI—Gastric cancer


M. Pisarska1, M. Wierdak 1, M. Dec1, M. Chrusciel2, J. Kulawik1, P. Major1, A. Budzynski1, M. Pedziwiatr1 12nd Department of General Surgery, Jagiellonian University Medical College, KRAKOW, Poland; 2Department of Endoscopic, Metabolic and Soft Tissue Tumor Surgery, University Hospital Krakow, KRAKOW, Poland

Aim: To determine the factors affecting length of hospital stay (LOS) in patient after laparoscopic total D2 gastrectomy (LTG) combined with ERAS protocol

Methods: AND PROCEDURES: The study enrolled 90 patients (60 men and 30 women, mean age 62.2 ± 11.8 years) who underwent elective LTG due to gastric adenocarcinoma between 2015 and 2017. Demographic and surgical parameters, compliance with ERAS protocol, recovery parameters, postoperative complications and readmissions were analyzed. Discharge from hospital after more than median hospital stay was considered as prolonged LOS (primary length of stay after surgery, excluding readmissions). We evaluated factors that potentially may influence LOS . Logistic regression models were used in univariate and corrected multivariate analyses, in order to identify the factors related to prolonged LOS.

Results: The median LOS after LTG in the studied group was 5 (4–8) days. 41 patients (45.5%) required prolonged hospitalization. Univariate logistic regression showed that the following factors were related to prolonged LOS: Peritoneal drainage on the first postoperative day (POD-1), Prolonged (> 24 h) catheterisation, No tolerating oral diet on POD-1 and postoperative complications, Multivariate logistic regression showed that only complications (OR = 3.72; 95% CI: 1.15–12.03), No tolerating oral diet on POD-1 (OR = 6.44; 95% CI: 2.22–18.66), and Presence for peritoneal drainage on 1 POD (OR = 4.06; 95% CI: 1.26–13.14), prolonged LOS.

Conclusions: Prolonged LOS following LTG with ERAS Protocol is strongly associated with the presence of postoperative complications, need for prolonged peritoneal drainage, and no tolerance of oral diet on POD-1. In our analysis, neither demographic nor operational factors had an impact on prolonged hospitalization.

O170—UPPER GI—Gastric cancer


N. Belev Surgical Department, Eurohospital, PLOVDIV, Bulgaria

Aim: Our aim is to established the effectiveness of combined radical laparoscopic gastric surgery with PIPAC in advanced gastric cancer for the prevention and treatment of PC.Object.Laparoscopic gastrectomy show better postoperative results in comparison to open surgery while having the same post surgical oncologic results. Peritoneal spread in gastric cancer is generally observed in 40 to 50% of the patients. Pressurized intraperitoneal aeorosol chemotherapy (PIPAC) is based on breaking up chemotherapy agents into particles of 10–15 microns and delivering them in a concentration of 10% of the systemic dose under pressure of 15 mmHg for 30 min. Prevention and therapy of PC is the main indication for PIPAC which have promising initial reults.

Material and methods: Patients with resectable advanced gastric cancer with high risk of PC are candidates for this study. In prospective 12 patients had laparoscopic gastrectomy (7 total and 5 subtotal) with D2 lymph node dissection . After finishing the reconstructive stage we applied PIPAC for 30 min. This procedure was repeated after 30 days for a total of 3 times. We analyzed retrospectively 14 laparoscopic gastrectomies for a past period of 1 year (poorly differentiated, diffuse type) actively searching for PC.

Results: Two postoperative complications (16.6%) were established in the laparoscopic surgery group with PIPAC (internal pancreatic fistula, oesophago-jejuno anastomotic leak) and 3 complications (21,4%) in the retrospective group (internal pancreatic fistula, duodenal stump leak, oesophago-jejuno anastomotic leak, all Clavien-Dindo-II). In 8(57%) of the retrospective patients PC, was established at the end of the first year after surgery. Three of the patients in the aerosol group have reached the end of the first year with no data supporting PC, the others remain to be analyzed.

Conclusion: PIPAC has better pharmacological capabilities compared to HIPEC and systemic chemotherapy for the treatment of PC as in vitro and animal studies and clinical data support this statement. RCT are needed for complete and exact validation of this method.

O171—UPPER GI—Gastric cancer


C. Huang, Q. Chen, Z. Liu, Q. Zhong, C. Zheng, P. Li, J. Xie, J. Wang, J. Lin, J. Lu, L. Cao Department of Gastric Surgery, Fujian Medical University Union Hospital, FUZHOU, China

Purpose: To investigate the prognostic effects and risk factors of the omission and delay of postoperative chemotherapy of II/III gastric cancer (GC), with the goal of providing a reference for interventions of related departments.

Methods: The clinicopathological data of 1520 patients undergoing radical gastrectomy for II/III GC were collected and retrospectively analyzed. We defined the chemotherapy delayed until more than 60 days after radical gastrectomy and the complete omission of chemotherapy as unacceptable chemotherapy initiation (UAC group), while the chemotherapy conducted within 60 days of radical gastrectomy was defined as acceptable chemotherapy initiation (AC group). The survival between the two groups was compared, and the trends and risk factors of UAC were analyzed.

Results: The OS and DFS of the UAC group patients were significantly inferior to those in the AC group (p < 0.001). The OS and DFS of the patients in UAC group were close to those of the patients without chemotherapy (p > 0.05). Cox multivariate analysis demonstrated that UAC is an independent predictor of OS (p < 0.05). Logistic analysis showed female sex, old age, a self-paid status, a very low social status, a high ASA score, an intra-abdominal surgery history, and serious postoperative complications were independent risk factors of UAC (p < 0.05).The radar chart shows the risk factors of UAC changed with time: the number of self-funded patients with an extremely low social status gradually decreased from 2011 to 2014 (0–3.2%); however, it increased again in 2015 (4.5%).

Conclusion: UAC after radical gastrectomy is an independent risk factor for the prognosis of II/III stage GC patients. However, no significant decline of UAC has been achieved recently and should call for the attention of both government and clinicians.

O172—UPPER GI—Gastric cancer


C.H. Kim, Upper GI surgery, The catholic University of Korea, Incheon St. Mary’s hospital, INCHEON CITY, Korea

Background: The aim of this study is to present our ten years of experience in terms of the evolution of surgical procedures and short and long term clinical outcomes of totally laparoscopic distal gastrectomy with uncut Roux-en-Y in comparison with Billroth-I technique.

Study Design: We retrospectively reviewed the medical records of 458 patients who underwent totally laparoscopic distal gastrectomy with uncut Roux-en-Y and Delta-shaped Billroth-I anastomosis from December 2004 to December 2014 at the Department of Surgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea. The evaluated parameters included patients and tumor characteristics, operative details, postoperative complications and endoscopic findings of the gastric remnant at postoperative 1 and 5 years.

Results: The total number of patients who underwent totally laparoscopic distal gastrectomy with uncut Roux-en-Y and Delta shaped Billroth-I anastomosis was 244 and 214, respectively. The mean reconstruction time was longer in uncut Roux-en-Y than in Delta shaped Billroth-I, (30.5 ± 14.5 vs. 13.6 ± 10.3 min, p < 0.001). The uncut Roux-en-Y was used more cartridge than Delta shaped Billroth-I anastomosis (6.9 ± 1.2 vs. 6.2 ± 1.0, p < 0.001). However there was no significant differences in operation time, estimate blood loss, number of retrieved lymph node and postoperative course between reconstruction methods. Postoperative complications more than Clavien-Dindo grade IIIa occurred in 22 cases (4.8%) of postoperative early complications and 14 cases (3.1%) of late complications. The endoscopic findings showed excellent short and long-term outcomes in terms of very low incidence of bile reflux and reflux-induced remnant gastritis in uncut Roux-en-Y compared with Delta shaped Billroth-I anastomosis.

Conclusions: Uncut Roux-en-Y gastrojejunostomy was a useful reconstruction method with totally laparoscopic distal gastrectomy for cancer, especially for diverting enteral contents from the remnant stomach and preventing remnant gastritis. Therefore, it is recommended for young patients with early stage disease who have a long time to live after distal gastrectomy for cancer.

Key words: uncut Roux-en-Y, Billroth-I, Totally laparoscopic surgery, Stomach

O173—UPPER GI—Gastric cancer


C. Huang 1, Z. Huang1, Q. Chen1, C. Zheng1, P. Li1, J. Xie1, J. Wang1, J. Lin1, J. Lu1, L. Cao1, M. Lin1, R. Tu2, J. Lin1 1Department of Gastric Surgery, Fujian Medical University Union Hospital, FUZHOU, China; 2Fujian Medical University Union Hospital, FUZHOU, China

Purpose: To determine the ideal indications of adjuvant chemotherapy(AC) in patients with stage IIa gastric cancer (T3N0M0 and T1N2M0) according to the 7th American Joint Committee on Cancer (AJCC).

Method: 1593 gastric cancer patients with T3N0M0 or T1N2M0 stage were identified from Surveillance, Epidemiology,and End results (SEER) database in 1988.1–2012.12. Cox multiple regression, nomogram and decision curve was used.External validation was performed using database from Fujian Medical University Union Hospital(FJUUH)(n = 241) and Italy IMIGASTRIC center(n = 45).

Results: Cox multiple regression analysis showed that the risk factors that affected OS in Patients with AC were age > 65 years old, T1N2M0, LN dissection number = 15, tumor size > 20 cm, and non-adenocarcinoma. Then a nomogram was constructed to predict 5-year OS and divided patients into a high-benefit from AC (points = 188) or a low-benefit (points > 188) according to a recursive partitioning analysis.OS was significantly higher for the high-benefit patients in the SEER database and the FJUUH dataset than in the non-AC patients (Log-rank < 0.05), and there was no significant difference in OS between low-benefit patients and non-AC patients among the three centers (Log-rank = 0.154, 0.470, and 0.434, respectively). The decision curve indicated that the best clinical effect can be obtained when the threshold probability is 0–92%.

Conclusion: Regarding the controversy over whether T3N0M0 and T1N2M0 gastric cancer patients should be treated with AC, this study presents a predictive model that provides concise and accurate indications. These data show that high-benefit patients should receive AC.

O174—UPPER GI—Gastroduodenal diseases


E. Kanehira, Takashi Tanida, Kodai Takahashi, Yuichi Obana, Aya Kamei Kanehira, Kazunori Sasaki Department of Surgery, Medical Topia Soka, SOKA, Japan

Background: To avoid excessive sacrifice of the tissue surrounding the gastric SMT (submucosal tumor) in stapling wedge resection, we carry out CLEAN-NET (combined laparoscopic and endoscopic approach for neoplasia with a nonexposure technique). We describe the operative technique of CLEAN-NET and demonstrate its clinical results.

Operative technique: The seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. When seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. The mucosa is then transected with a stapling device to execute full-thickness resection of the specimen. Finally, the seromuscular defect is repaired by hand-sewn suture.

Results: Since December 2015, CLEAN-NET has been performed in 57 patients with gastric SMTs. All tumors were resected en-blocwithout rupture. The average operation time ranged from 50 to 220 min with an average of 101.7 min. The postoperative course was uneventful. Microscopically the surgical margin was tumor-negative (R0 resection) in all cases. The margin width was small with an average of 5.4 mm ± 2.5.

Conclusions: CLEAN-NET is a useful option in the laparoscopic surgical treatment of gastric SMT, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided.

O175—UPPER GI—Reflux-Achalasia


M. Forsell, M. Bjelovic Department of Minimally invasive Upper Digestive Surgery, University Clinic for Digestive Surgery, BELGRAD, Serbia

Aim: For the past 40 years prevailing surgical acid-reflux treatment has focused on supporting the LES, mainly performed by gold standard Nissen Fundoplication, where a wrap is formed around and compresses the LES. This procedure has disadvantages such as dysphagia, inability to burp and vomit, and long-term dystrophy of the wrap which becomes thin, inelastic, and fibrotic. Our aim was to; develop a new treatment for acid reflux which does not affect the food passageway, as well as avoid increasing reuse of PPI’s long-term caused by the fibrotic degeneration of the fundus wrap.

Methods: A new device, RefluxStop™, is placed invaginated in the fundus to keep LES down in the abdomen and treats acid-reflux without affecting the food passageway.

In a multicenter clinical trial with 50 patients, the one-year results are presented using GERD-HRQL as a screening tool and 24-hour pH monitoring at failure, defined as < 50% improvement since baseline in the GERD-HRQL score.

Results: The clinical results support a potential paradigm shift in the treatment of acid-reflux.

The GERD-HQRL score improved from 29 to 4 at 1 year, and the side effects relating to the compression of the food passageway disappear. The half-year surgical control 24-hour pH-monitoring (total time pH < 4) reduced from 16.3% to 0.85%. No ADE (adverse device events) occurred and no devices were explanted.

Conclusion(s): These results support that existing reflux treatments are based on the wrong assumption: the LES does not need to be supported and/or compressed to treat acid-reflux. Compression of the food passageway causes well-known side effects, and the result also indicates an improved efficacy compared to a literature review and meta-analysis on Nissen fundoplication.

O176—UPPER GI—Reflux-Achalasia


A. Addo, A. Park, A.S. Weltz, Z. Sanford, H.R. Zahiri, R. Lu, A. Borda General Surgery, Anne Arundel Medical Center, ANNAPOLIS, United States of America

Aim /Background: Minimally invasive antireflux surgery has been shown to be safe and effective for the treatment of gastroesophageal reflux (GERD) in elderly patients. However, there is a paucity of data on the influence of advanced age on long-term quality of life (QoL) and perioperative outcomes after laparoscopic antireflux surgery (LARS).

Method: A retrospective study of patients undergoing laparoscopic fundoplication for GERD or as a component of hiatal hernia surgery between February 2012 and June 2018 at a single institution was conducted. Patients were divided into four age categories, < 50 </i > , 50–65 </i > , 65–75 </i > ,=75 </i > . Perioperative data and quality of life (QOL) outcomes were collected and analyzed. QoL information was obtained using the following four validated survey instruments: the Reflux Symptom Index, Gastroesophageal Reflux Disease-Health Related Quality of Life, Laryngopharyngeal Reflux QOL, and Swallowing QOL questionnaires.

Results: A total of 492 patients [< 50(n = </i > 75),50-65(n = </i > 179),65-75(n = </i > 144), = 75(n = </i > 94)] with mean follow-up of 21 months were included in the final analysis. Advancing age was associated with increased likelihood of comorbid disease, including hypertension (OR 1.93, p < </i > .001), dyslipidemia (OR 1.36, p = </i > .001), coronary artery disease (OR 1.70, p < </i > .005), arrhythmia (OR = 3.23, p = </i > .010), COPD (OR 3.00,p < </i > .001), and renal disease (OR 1.97, p = </i > .010). Older patients were significantly more likely to present with advanced disease requiring Collis gastroplasty (OR 2.09) or concurrent gastrostomy tube placement (OR 3.20). Accordingly, older surgical patients required increased operative time (ß 6.29, p < </i > .001), length of hospital stay (ß 0.56,p < </i > .001) and increased likelihood of intraoperative complications (OR 2.94, p = </i > .003) and reoperations (OR 2.36, p < .05). However, postoperative complication rates were parallel among all age groups. Additionally, patient-reported QoL outcomes and postoperative satisfaction trended favorably across all age groups.

Conclusions: Among older patients, there is a greater risk of intraoperative complications, reoperation rates as well as longer operative time and LOS after LARS, supporting more advanced disease. However, a long-term QoL benefit is demonstrated among elderly patients who have undergone this procedure parallel to younger groups. Rather than serving as an exclusion criterion for surgical intervention, advanced age among patients with pathologic reflux should not deter rendering therapy to this group. Enhanced outcomes are achieved through efforts towards preoperative optimization and utilization of advanced technical approaches.

O177—UPPER GI—Reflux-Achalasia


R. Gefen 1, M Gad2, R. Ram2, H. El-Harub2, Y. Mintz2 1General surgery, Hadassah Hebrew University Medical Center, JERUSALEM, Israel; 2General surgery, Hadassah medical center, JERUSALEM, Israel

Background: The type of fundoplication—complete or partial is still controversial for the surgical treatment of GERD. Laparoscopic Toupet (2700 wrap) fundoplication has less post op dysphagia and gas bloating compared to Nissen fundoplication (3600 wrap) and is advised to be the procedure of choice when esophageal manometry findings are abnormal, however it is considered by some less effective and more difficult to perform. The aim of this research was to determine in the functionality and efficacy of the different types of fundoplication.

Methods: Explanted pigs stomachs weighing 45–60 Kg were studied. Two different studies of the LES were performed: distensibility and failure point (occurrence of reflux according to volume added to the stomach). For both studies we first disrupted the lower esophageal sphincter using a RigiflexTM dilating balloon. We then performed three different fundoplications- Nissen, Toupet, Dor and measured the distensibility of the EGJ after each fundoplication. The Failure point was determined following each fundoplication type.

Results: we used 12 pig stomachs for the distensibility study and 11 pig stomachs for the failure point study. There was no statistically significant difference between the Nissen and Toupet fundoplications when distensibility was measured, however the EGJ was more distensible following Dor fundoplication (p = 0.008 for Nissen, 0.016 for Toupet). When the failure point was measured, Nissen fundoplication was significantly more effective than Toupet, and Toupet was significantly more effective than Dor (p = 0.016,p = 0.017 respectively)

Conclusions: We studied the differences between the mechanical effects on the EGJ following three different fundoplications, encompassing 3600, 2700, and 1800 of the esophagus. We demonstrated that there is a significant difference between Dor fundoplication and Nissen/Toupet when distensibility was measured. There was no difference in the distensibility of the EGJ following a 3600 or 2700 wrap. There was, however a significant difference of effectiveness between all three fundoplications. These findings suggest that the 3600 and 2700 fundoplications have similar functionality while the 3600 wrap mechanically prevents possible reflux and support proponents of Toupet fundoplication rather than Nissen due to the similar functional results while decreasing the post op dysphagia and gas bloating complications.

O178—UPPER GI—Reflux-Achalasia


J.S. Ljungdalh 1, K.H. Rubin2, J. Durup3, K.C. Houlind4 1Department of Surgery, Kolding Hospital, a part of Hospital Lillebaelt, KOLDING, Denmark; 2OPEN—Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark, ODENSE, Denmark; 3Department of Surgery, Odense University Hospital, ODENSE, Denmark; 4Department of Vascular Surgery, Kolding Hospital, a part of Hospital Lillebaelt, KOLDING, Denmark

Aim: To describe patients undergoing surgical treatment of incident gastro-oesophageal reflux disease and the use of anti-reflux treatment in a Danish population-based cohort.

Methods: All adult Danes 2000–2015 undergoing upper endoscopy and receiving a diagnosis of GERD within 90 days were identified. Patients with previously diagnosed GERD, peptic ulcer-disease, Barrett’s oesophagus or cancer of the gastrointestinal tract were excluded. In this study, only patients undergoing anti-reflux surgery within two years of GERD-diagnosis were subsequently included.

Age, sex, Charlson Comorbidity Index (CCI), anti-reflux surgery (primary and re-operative) and endoscopic dilatation were identified using the Danish National Patient Registry. Mortality was identified using the National Civil Registry. Pharmacological treatment of GERD (Proton pump inhibitors, H < su2 </su-blockers and other prescription anti-reflux drugs) as well as use of non-steroid anti-inflammatory drugs (NSAID) and anti-thrombotic treatment were identified using theThe Danish National Prescription Registry. All data was linked on an individual level using the unique identification number that all Danish citizen are assigned to at birth or first immigration.

Results: A total of 674 first-time fundoplications were performed, hereof 98.1% performed laparoscopically (n = 661) and 1.9% performed using open technique (n = 13). At one-year follow-up, 4.9% (n = 33) had undergone endoscopic dilatation and 2.1% (n = 14) had undergone reoperation. The 90-day mortality was < 0.5%.

Patients had a median age of 46 years (18–80 years) and were predominately male (57.9%—n = 390). A total of 93.9% had CCI 0 (n = 633). Diagnoses were GERD with esophagitis (66.9%—n = 451), GERD without esophagitis (31.5%, n = 212) and GERD without specification (1.6%, n = 11).

Before initial endoscopy, 91,7% (n = 618) used at least one type of anti-reflux drug, dropping to 32.2% (n = 217) in the year after anti-reflux surgery. However, even when censoring patients with Barrett’s esophagus or peptic ulcer disease after initial endoscopy and patients undergoing concomitant treatment with NSAIDs or antithrombotic drugs, 27.7% still used at least one type of anti-reflux drug after surgery.

Conclusion: In this population-based study, anti-reflux surgery was safe and lowered the use of pharmacological treatment. However, even when adjusting for competing reasons for use of anti-reflux drugs, 27.7% used at least one type of anti-reflux drug one year after surgery.

O179—UPPER GI—Reflux-Achalasia


M. Paranyak, V. Grubnyk Surgery, Odessa national medical university, ODESSA, Ukraine

Nearly 10% of patients who undergo laparoscopic anti-reflux surgery at long-term follow-up need for surgical reintervention mostly because of hiatal hernia (HH) recurrence, wrap migration or disruption.

Purpose: The aim of our prospective study was to evaluate and compare several technics of wrap fixation and determine whether modified Nissen fundoplication (MNF) reduce failure rate in the long term follow up.

Materials and methods: This was a prospective, randomized, controlled trial. From November 2012 to October 2014 one hundred and thirty-eight GERD patients who underwent anti-reflux surgery were divided into two groups. Excluded criteria for our study ware diagnosed hiatal hernia (HH) type III. In the I group which include 87 patients we performed the following manipulations: NF was supplemented with suturing wrap to the diaphragmatic crura (52 patients) on each side using two non-absorbable stitches. Such technique permit us to create more symmetrical wrap. In case of weak conditions of crura or short esophagus (35 patients) fundoplication wrap was sutured to the body of stomach using two non-absorbable stitches on each side. Control group (51 patients) underwent classic Nissen fundoplication (NF) without wrap fixation. All patients were assessed before and after surgery using validated symptoms and quality of life (GERD-HRQL) questionnaires, 24-h impedance-pH monitoring and barium-swallow.

Results: Baseline characteristics were similar between groups. There were no conversion to open procedure or mortality. Mean hospitalization was 2.7 days ± 1.4 days. At 41,6 months (range 18-–57) of follow-up, the overall rate of complications after MNF was 1,14% (1 HH reccurence) and NF 7,84% (3 HH reccurence, 1slipped wrap). Patient in MNF group show significant improvement in GERD-HRQL score, from 19.3 ± 13.2 (preoperatively) to 4.3 ± 3.9 (postoperatively) (p? < ?0.001). Complete PPI independence was achieved in 91%. In the II group of patients mean GERD-HRQL score decline from 18.7 ± 11.9 (preoperatively) to 9.3 ± 7.7 (postoperatively), postoperative PPI treatment was necessary in 29%.

Conclusions: According to our study MNF minimized risk of slipped wrap and intrathoracic migration of the wrap and can make positive impact on reducing the failure rate of laparoscopic anti-reflux surgery.

O180—UPPER GI—Reflux-Achalasia


S.A. Antoniou1, A. Andreou 2, D.I. Watson3, D. Mavridis4, N.K. Francis5, P. Chitsabesan6 1Surgical Service, Royal Devon & Exeter NHS Foundation Trust, EXETER, United Kingdom; 2Department of Colorectal Surgery, York Teaching Hospital NHS Foundation Trust, YORK, United Kingdom; 3Discipline of Surgery, College of Medicine and Public Health, Flinders University, ADELAIDE, Australia; 4School of Education, University of Ioannina, IOANNINA, Greece; 5Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, YEOVIL, United Kingdom; 6Department of Surgery, York Teaching Hospital NHS Trust, YORK, United Kingdom

Aims: Comparative evidence across laparoscopic antireflux procedures does not exist. Aim of this project was to identify direct comparative evidence between laparoscopic antireflux procedures and synthesize evidence using network meta-analytical methods.

Methods: The databases of Medline, AMED, CENTRAL, OpenGrey were interrogated. Pairwise meta-analyses for each pair of interventions using a random-effects model and network meta-analysis in Stata was performed using the mvmetacommand and self-programmed Stata routines. Differences between direct and indirect evidence were explored by comparing direct and indirect estimates though computing the inconsistency factor within each closed loop of evidence. The ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmetacommand in Stata. A hierarchy of the competing interventions was obtained using rankograms. Quality of evidence was assessed using GRADE-NMA and the CINeMA application.

Results: Forty-three publications reporting on 32 randomized trials and some 1892 patients were identified. The network of treatments formed a closed loop between 270°, 360° and anterior 180°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 360°, 270°, anterior 180° and anterior 90° were equally effective in the control of heartburn and this was supported by low quality of evidence according to GRADE-NMA. The odds for dysphagia were lower for anterior 90° (high quality evidence), anterior 120° (moderate quality evidence), 270° (moderate quality evidence) and proton-pump inhibitors (moderate quality evidence) compared to 360°. The odds for gas-bloat were lower for 270° and anterior 90° compared to 360° (low quality evidence). The odds for regurgitation, morbidity and reoperation were similar across treatments, albeit these were associated with very low quality evidence. Anterior 120° had a 49% probability of being the best treatment in terms of dysphagia.

Conclusion: Under consideration of treatment effect estimates, evidence quality as assessed with GRADE-NMA and other parameters, anterior 90°, anterior 120° and 270° should be preferred over 360°. Further research needs to focus on the comparison between 90° and 120°/270°.

O181—UPPER GI—Reflux-Achalasia


L. Navaratne, A. Isla Upper GI Surgery, Northwick Park Hospital, LONDON, United Kingdom

Aims: We have recently demonstrated that the tension of crural closure can be reliably measured intraoperatively (ALSGBI Conference December 2018). The aims of this study were to further characterise tension at the diaphragmatic hiatus from our prospective pilot study of 72 patients.

Methods: A prospective analysis was performed of patients undergoing laparoscopic hiatal hernia repair between April 2017 and December 2018. 72 patients underwent crural tension measurement intra-operatively. 24 patients had a pre-operative CT scan of the abdomen within one-year of surgery. Hiatal surface area (HSA) was measured intraoperatively and a Sauter-FH50 Universal Digital Force Gauge was used to measure the tension of crural closure during cruroplasty. Outcome measures included the mean tension of the crural closure and the presence of muscle splitting during the cruroplasty.

Results: For all patients, the mean crural tension measurement was 2.93 N and the mean HSA was 543 mm2. Pre-operative CT was positively correlated with post-dissection intra-operative HSA (r = 0.5402, p = 0.0064), however, strength of association was weak (r2 = 0.2918) and CT consistently overestimated the size of hiatal defect intra-operatively (mean of differences 404 mm2, p = 0.0016). Crural tension was positively correlated with age (r = 0.3321, p = 0.0044), hiatal height (r = 0.6023, p < 0.0001), hiatal width (r = 0.766, p < 0.0001) and HSA (r = 0.7753, p < 0.0001). Crural tension was correlated to the hiatal width to height ratio to assess the shape of defect and there was positive correlation (r = 0.4072, p = 0.0004). Tension was calculated for the posterior and anterior halves of the suture cruroplasty. Anterior tension was significantly higher when compared to posterior tension (3.26 N vs 2.59 N, p < 0.0001). 16 patients had evidence of muscle splitting during the cruroplasty. The group with muscle splitting were significantly older (66 vs 53, p = 0.0029), had larger HSA (910 mm2 vs 347 mm2, p < 0.0001) and higher crural tension (5.69 N vs 2.14 N, p < 0.0001). The lowest observed mean crural closure tension causing muscle splitting was 3.52 N.

Conclusion: There is now a possibility to optimise this operation with objective measures 100 years after it was first described. Initial findings suggest that crural closure up to ~ 4 N could be the permissible tension threshold for suture cruroplasty and higher tension may benefit from the use of mesh reinforcement.



R. Broderick, K.H. Fuchs, A. Lee, R. Dominguez, B.J. Sandler, S. Horgan Minimally Invasive Surgery, University of California San Diego, SAN DIEGO, United States of America

Background: Endoscopic Submucosal Dissection (ESD) and Endoscopic Full Thickness Resection (EFTR) are advanced endoscopic techniques which can be time consuming using traditional endoscopic instruments. A new endosurgery platform, designed by Fortimedix Surgical, was developed featuring flexible articulating instruments to use in combination with a standard flexible endoscope. The platform is intended to perform endoscopic cutting, dissecting, and hemostasis.

Aim: Evaluate feasibility of the platform in the upper GI-Tract.

Project Description: The platform was tested in a dry esophageal model as well as a second series with a porcine esophagus and stomach. The system has an external docking station affixed to the operative table to stabilize both flexible instruments for the right and left hand of the surgeon. At the tip of the endoscope, a cap containing instrument lumens is attached to allow advancing and removing the flexible instruments. The endoscope with the cap and instrument lumens attached is advanced via an overtube with outer diameter 18.5 mm. In the first series, flexibility and range of motion of the end-effectors was assessed. Additionally, the ability to advance the instruments to the intraluminal target area from the docking station and along the scope was evaluated. In the second series, the functional capabilities of the system and instruments were evaluated in a porcine model.

Preliminary Results: : In the dry model, the platform was adequately deployed to the target then range of motion was tested as well as cutting and grasping gastric wall with instrumetn triangulation achieved. The grasping forceps provided enough force to pull the mucosal wall and expose the dissection plane. In the pig model, the distal esophagus and stomach could successfully be accessed and platform deployed. ESD was performed using newly designed flexible articulating scissors, dissection-hook, and graspers with good triangulation and sufficient grasping force with traction/counter-traction. The new Fortimedix Surgical endo-surgery platform applied to a standard flexible endoscope is feasible to perform ESD. Future studies are planned to determine learning curve and compare it to traditional endoscopic instruments.



A. Takai, K. Sakamoto, M. Takashi, T. Ustunomiya, H. Masahiko, Y. Ueno, H. Inoue, K. Ogawa, Y. Takada HBP surgery, Ehime University, TOON, Japan

Background: In laparoscopic surgery, we usually observe the organs in the same direction to avoid a mirror-image situation. Therefore, we are unable to recognize how far the dissection has proceeded on the other side of the target organs or lesions, especially when the plane of dissection is under the mesentery or organs. This becomes a problem not to understand how far the dissection has progressed and how much more dissection is needed.

Aim: To solve this problem, we developed a laparoscopic device with tip illumination.

Project description: The device is configured by the long and narrow part made of polycarbonate resin and a battery-powered light-emitting diode to illuminate the tip by shining light through the polycarbonate resin. During the surgery, the tip of the device is inserted into the deepest part of the dissection area, and the transmitted light indicates how far the dissection has progressed. The tip of the device has a prism structure and light is emitted in a direction perpendicular to its axis. Tip position can thus be more clearly identified even with insertion in the same direction as the laparoscopic view. To verify the utility of this instrument, laparoscopic surgeries were performed in a porcine model and cadavers.

Preliminary results: We performed some laparoscopic surgery such as the medial-to-lateral approach to the white line of the left side of the descending colon for sigmoidectomy, dissection of the posterior surface of the pancreas to the upper edge of the pancreatic body or splenic artery for distal pancreatectomy, and the separation of the anterior surface of the inferior vena cava from the liver to the area between the right and middle hepatic vein for right hepatectomy. We quickly and easily identified the deepest part of the dissection area even if identification had been difficult using other techniques such as placing gauze in the deepest position, inserting forceps into the dissection area or simply depending on the experience of the operator.



A. Ezzat 1, R. Thakkar2, A. Kogkas2, G. Mylonas2 1Human-centred Automation, Robotics and Monitoring in Surgery,Faculty of Surgery, Imperial College London, LONDON, United Kingdom; 2Human-centred Automation, Robotics and Monitoring in Surgery (HARMS) Laboratory, Imperial College London, LONDON, United Kingdom

Background: Recent advancements within surgery have seen artificial intelligence transform traditional approaches. Robotic assistive devices have demonstrated particular success, as safe and cost effective, and are widely supported via industry and local government as a step closer to the future standard of practice. An example of seamless and touchless robotic assistive technology is based on touchless and interactive eye tracker glasses worn by the surgical team thereby enabling the team to perform wider surgical tasks, more efficiently and reduced human error. We introduce a perceptually-enabled, Smart Operating Room (Smart-OR) based on a novel real-time framework for theatre-wide 3D gaze localisation in a mobile fashion. This framework enables dynamic gaze based user interaction with a robotic scrub nurse to facilitate meaningful practical integration of human and technology intra-opertively.

Aims: We tested participant acceptability of a novel robotic scrub nurse during simulated surgery.

Project description: Surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses to select surgical instruments on a screen. The robotic scrub nurse(RN) picked up and transferred the instrument to the surgeon. The study compared human nurse(HN) vs RN. Gaze-screen interaction was based on a 3D gaze framework we developed with synergy of conventional wearable eye-tracking, motion capture system and fixed in space RGB-D cameras for real-time 3D reconstruction of the environment. NASA-TLX and Van der Laan’s technology acceptance questionnaires were collected and analysed using ANOVA.

Preliminary results: Overall, 7 teams of surgeons(ST) and scrub nurses(SN) participated. NASA TLX feedback for ST and SN revealed no significant difference between in mental, physical or temporal demand. Importantly, ST and SN reported no significant difference in task overall performance. ST reported more significant frustration with RN vs HN. Van der Laan’s scores showed positive usefulness and satisfaction scores in using the RN platform. Overall, all outcomes were more positive by SN vs RN.

Conclusions: This is the first platform of its kind. Overall, quantitative and qualitative feedback was positive. The source of frustration has been understood and we believe it can be improved by appropriately modifying robot behaviour. Importantly,there was no difference on perception of performance.



K.H. Fuchs, K. Neki, A. Lee, R. Dominguez Profeta, B. Sandler, S. Horgan Surgery, UC San Diego, LA JOLLA, United States of America

Background: Endoscopic tumor resections in the GI tract may be facilitated by more advanced instruments for dissecting and suturing. We have focused on developing an endoscopic suturing technique using a standard flexible pediatric endoscope with new, flexible instruments allowing for complex end-effector movements.

Aim: Perform flexible endoscopic suturing using a standard flexible scope in the GI tract

Project description: A standard flexible pediatric endoscope and a standard gastroscope were used for testing the new technique. Via an overtube, the endoscope and newly designed Fortimedix Surgical flexible instruments (needle holder; grasper) with a diameter of 5 mm were inserted into the esophagus. Suture training was performed in an experimental setting in a box in the dry lab and porcine model . The flexible needle holder was advanced into the esophagus next to the scope, and a suture of the esophageal wall was performed, followed by extracorporeal knot-tying with 3 knots. The test series consisted of training with both resident trainees and surgeons to evaluate the learning curve. Each participant performed sutures on the box model and in the pig-esophagus. Feasibility, duration of the different steps, and handling problems were documented.

Preliminary Results: Test series 01 (box training on esophago-gastric explant) with prototype 01 showed good feasibility. Suturing was possible in 9 out of 10 attempts. Median duration for single bite: 6 min (5–30); knot-tying: 5 min (2–8). Test series 02 (training in pig-model) with prototype 02 showed improved feasibility with better flexibility of instrument shaft: Median duration of double bite: 8 min (7–15); knot-tying: 2 min (1–5), overall duration intraluminal esophageal double bite suture and closing with 3 knots: median duration: 13 min (12–20).

Conclusions: The new flexible Endosuture instruments seem feasible to use and perform dependable intraluminal sutures. The training period and learning curve is short and the objective is to apply this system clinically for closure of perforations and fistulas.



L. Cao1, H.L. Kaan 2, X. Li1, P.T. Phan1, A.M.H. Tiong1, K.Y. Ho3, P.W.Y. Chiu4, S.J. Phee1 1School of Mechanical and Aerospace Engineering, Nanyang Technological University, SINGAPORE, Singapore; 2General Surgery, National University Hospital, SINGAPORE, Singapore; 3Gastroenterology, National University Hospital, SINGAPORE, Singapore; 4Surgery, Chinese University of Hong Kong, HONG KONG, Hong Kong

Background: Ideally, endoscopic suturing should mimic surgical closure as the latter is stronger than most endoscopic closure devices. However, endoscopic suturing is challenging due to the confined endoluminal space and lack of dexterity of current endoscopic instruments. We have developed a novel robotic suturing device to overcome these problems.

Aim: This animal study aims to demonstrate the feasibility of this device in closing perforations.

Method: The trial was conducted on an anaesthetized live pig. A double-channel colonoscope was first inserted into the rectum. Following saline lift, a 10 mm submucosal incision was created in the rectum to simulate a perforation. The robotic suturing device and grasper were inserted into the two colonoscope channels, allowing the endoscope to remain in position for tool exchanges or needle reloading. Both the effectors were intuitively tele-operated by the user via a robotic master console.

This robotic suturing device manipulated a curved, double-point needle (with a 10 cm 3-0 Vicryl suture) to penetrate tissues at desired orientations. The needle could be switched between both jaws of the device through a locking mechanism. This facilitated passing the needle through tissues to form stitches or through suture loops to form surgical knots. The articulated joints and five degrees of freedom allowed dexterous steering to reach targets and triangulation with other tools in a confined space. The robotic grasper facilitated handling of tissue and suture.

Result: A total of four running stitches were performed and secured with a surgical knot by passing the needle through suture loops. The suture was cut and the needle was removed by the robotic grasper through the channel. 11 min and 4 min were required to stitch and tie the knot respectively. There was no complication.

Conclusion: Our novel endoscopic robotic device can suture perforations resulting from complex endoscopic procedures. As our suturing method is similar to laparoscopic and robotic suturing, closure using our device is expected to be as strong as a surgical through-and-through closure. When developed further, this device can be used to close full-thickness resection sites and orifices in transluminal endoscopic surgery.



J. Berger, M. Unger, L. Landgraf, A. Melzer Medical Faculty, University Hospital Leipzig, Innovation Center Computer Assisted Surgery, LEIPZIG, Germany

Background: Surgical robotics require a smooth integration into the operating room (OR). For this propose the IEEE 11073 SDC(Service-oriented Device Connectivity) standard has been developed in the OR.NET project. In preparation for a combined focused ultrasound and radiation therapy (FUS-RT) we have shown concepts and evaluations to position ultrasound and interventional devices with collaborative KUKA arms. However, the safe and intraoperative cooperation with multiple different OR-devices (e.g. an irradiation unit) requires a more sophisticated exchange of the robot’s information and functionality.

Aim: To realize a safe clinical integration, the aim of this work is to implement and evaluate a dynamic connection between the KUKA robots and other devices using the vendor-independent SDC communication standard.

Project description: A KUKA LBR iiwa 7 R800 robot (KUKA AG, Germany) was modeled inside the SDC standard for medical device communication. The interconnection with other devices was implemented and evaluated on a mobile platform to position a Clarius L7 wireless ultrasound transducer (Clarius Mobile Health Corp, Canada). All necessary information of the robot was represented in the medical device description of the SDC standard to be shared via network. For each joint of the robot arm the position, torque, stiffness, damping, velocity and functional-states were represented, resulting in a total of 42 parameters. The software was implemented in C ++ on a standard PC accessing the KUKA controller cabinet with ROS (Robot Operating System) via Ethernet. The accessibility of each parameter, as well as activation commands for planning and movement were tested with an SDC-consumer application.

Preliminary results: The SDC-provider functionality of the robot was successfully implemented, allowing for dynamic changes of the robot state during interventions. All appliances (SDC standard compatible) in the robots network can react to state changes and send movement and planning commands to the robot via activations. After testing, 100% of the 42 defined parameters are safely accessible. Implementing the medical device communication for the KUKA robot enables its integration into any networked operation room that supports the SDC standard. It is, therefore, ready to be set up and evaluated for the application of FUS-RT in a clinical environment.



A. Soares, S. Bano, D. Stoyanov, L.B. Lovat, M. Chand Wellcome / EPSRC Centre Interventional and Surgical Sciences, University College London, LONDON, United Kingdom

Background: Assessment of perfusion of the left colon with fluorescence during anterior resections for cancer changes surgical decisions in up to 19% of cases. Use of fluorescence has been shown to be associated with lower leak rates, and improved short- and long-term outcomes with reduced costs. Given the high incidence of colorectal cancer, fluorescence-guided perfusion assessment could be of great importance in contemporary surgical practice. However, there is currently no standardisation of this technique which represents a significant limitation to widespread adoption.

Aim: to standardise fluorescence-guided perfusion assessment in rectal anterior resection through a computer vision algorithm.

Project description: Videos were collected by a single surgeon in a referral centre for colorectal cancer treatment. Perfusion assessment was used before proximal colon division to identify the best location for transection. A bolus of indocyanine green was injected intravenously and a near-infrared camera used to assess perfusion through fluorescence.

Photographs of fluorescent imaging of the colon were analysed using a non-supervised learning algorithm called ‘K-means clustering’. The first step was to digitally subtract all background pixels, leaving only the area of interest of the colon. This area was then subsegmented into 2 ‘clusters’ corresponding to perfused and non-perfused areas. A mathematical model was applied based on the 2 sub-clusters centres to select the area for transection with optimal perfusion of the proximal colon.

Preliminary results: Representative images of proximal colon under perfusion assessment were presented to 8 expert surgeons. The optimal point for transection was selected based on their clinical judgement on previously delimited areas indicated by random letters. This was compared with the results from the automated segmentation using the algorithm (fig. 1). The area identified for section by the algorithm included the area selected by the expert surgeons in 87.5—100% of test cases.

These results need to be further validated due to high risk of overfitting. Next steps include the collection of multicentre data with a standardised fluorescence perfusion assessment. After robust training, the algorithm will be validated on real-time clinical data to ensure improved outcomes for patients, which is our ultimate goal.



M. Brancadoro1, C. Quaglia1, H. Abidi1, M.A. Bonino2, A. Menciassi1, A. Arezzo 2 1BioRobotic Institute, Scuola Superiore Sant’Anna, PONTEDERA, Italy; 2Department of Surgical Sciences, Università di Torino, TORINO, Italy

Background: Endoscopic Submucosal Dissection (ESD) is a flexible endoscopic technique that allows for an en bloc removal of lesions of the gastrointestinal (GI) tract. These procedures are typically time consuming due to the difficult control of the tools, and they often require around 95 min for removing lesions, that can reach 3-4 cm in diameter. The probability of intestinal perforation exceeds 18% and the hemorrhage risk ranges from 3.5% to 15.5%. A flexible robotic endoscope may offer a solution to overcome these limitations, by improving the degrees of freedom (DoF) and operational efficiency. Aim: Within this clinical panorama, the aim of this project is presenting the development of a novel miniaturized robotic device to be coupled to the tip of a traditional endoscope for the surgical dissection of GI neoplasms.

Project description: The robotic platform consists of the miniaturized robot, the actuator housing (hereafter called external platform), the control unit and the master console (i.e.,two Geomagic Touch phantom) to allow the user driving and control (Figure 1a). During the operation, one surgeon stands close to the patient to maneuver the endoscope for exploring the GI tract and reaching the target area. Another surgeon operates the miniaturized robot through the master console, carrying out the surgical procedure. The robot has been designed to be coupled to the tip of traditional flexible endoscopes of 14.5 mm in diameter. It exploits the flexibility of the endoscope for navigation through the intestine and integrates two-active robotic arms (i.e.,cautery and gripper) extending the DoFs, and thus enhancing the efficiency during complex tasks such as manipulation and surgical tissue dissection. Furthermore, the endoscope provides the optical system for visual feedback and one working channels for conventional instruments.

Preliminary results: Firstly, a mock-up that faithfully reproduces the miniaturized robot has been realized using a 3D printer machine (ProJet MJP 3600, 3D System, Inc.) to verify the feasibility of the design solution. After verifying the potentiality of the 3D printed prototype, a final device, with the same features (i.e.,DoF and geometry) of the 3D printed prototype, has been designed, fabricated and assembled (Figure 1b).



N. Wrzesinska, M. Szostek, J. Wawrzyniec, S. Willenberg Department of General, Endocrine and Vascular Surgery, Medical University of Warsaw, WARSAW, Poland

Background: Virtual and augmented reality has been widely used in many fields mainly for entertainment purposes. We think that it could be beneficial to use augmented reality in medical practice.

Aim: The aim of this study was to evaluate usefulness of 3D holographic images of patients anatomy displayed using augmented reality goggles during endovascular aortic repair (EVAR).

Project description: One of the major challenges during endovascular procedures is working on two dimentional x-ray images of three dimentional vascular anatomy. Using 3D holograms of patients anatomy could be beneficial during the EVAR procedure and could make the orientation in vascular anatomy easier for surgeon.

We performed two endovascular aortic repairs with the assists of Microsoft HoloLens -smart glasses using augmented reality. We used Carna Life application created by polish company MedApp. It was one of the first use of holograms during vascular procedures in the world (second and third stent-graft implantation using holographic imaging in the world).

Results: Two patients with abdominal aortic aneurysms, 79—years old male and 74—years old female, were operated on. Holograms of patient’s anatomy made from preoperative angio CT scans by polish company MedApp were displayed during the procedures using Microsoft HoloLens. Holograms could be displayed in any place and configuration using augmented reality, which means that the images did not interfere with the surgeon’s field of vision. Microsoft HoloLens use voice commends which permits the surgeon staying sterile.

Stent- graft implantations were successful. Both patients were discharged three days after the procedure and the hospitalization was uneventful.

Seeing precise patient’s vascular anatomy reconstructions in three dimention certainly helped us to navigate in a vascular tree. We believe that in the future this technology would enable to reduce the operation time and need for radiation.



M. Jansen, H.A.W. Meijer, M.P. Schijven Department of Surgery, Amsterdam UMC, location AMC, AMSTERDAM, The Netherlands

Background: Interaction with electronically controlled operating room (OR) systems embedded in modern surgical environments is everyday practice for surgeons performing Minimally Invasive Surgery (MIS). While there is a non-sterile operating nurse available in the OR, capable of interacting with these systems upon request by the surgeon, this indirect control is mostly slow, prone for error and disrupting surgical workflow. Facing an unanticipated and unwanted outcome may cause distress emotions. Distress emotions are undesirable when performing surgery, since they may impact available cognitive workload. Furthermore, they may result in negative communication, hampering OR-team empowerment and effective leadership. Both factors are known to negatively influence quality and safety in the OR.

Aim: The aim of the TedTrial is to investigate what setup best enables surgeons to interact with the endoscopic operating room setup during surgical procedures. As a result, disruptions of workflow, delays and errors may be reduced. Outcome parameters will be objectified using medical data recorder (MDR) derived output and biometric analysis using Hexoskin©. Subjective evaluation of outcome parameters is done using questionnaires.

Project description: The TedCube© system is a plug-and-play device enabling wearable sensors to act as a wireless alternative for a regular computer mouse, therefore enabling direct hands-free and sterile control of the OR. The study is an observational trial with three different arms: Intervention group 1) direct interaction by surgeon with OR environment using TedCube© and Myo™ armband, Intervention group 2) direct interaction of surgeon with OR environment using Tedcube© and Plantronics© wireless microphone headset. The third arm is the control group using indirect interaction of surgeon with OR environment using third-person computer interaction.

Main endpoint of study is the number of workflow disruptions due to the operation of laparoscopic OR equipment. Secondary endpoints are error rate, delay, team communication, subjectively reported frustration and satisfaction with the system and objectively measured stress as symptom of frustration and anger as distress emotions.

Preliminary results: Primary and secondary endpoints of study are compared among groups. It is anticipated that reduction of miscommunication, error and delay may result in a reduction of distress emotions. Trial start is expected Q1 2019.



M. Barberio 1, V. Agnus1, F. Longo1, C. Fiorillo1, B. Seeliger1, A. Saadi2, M. Worreth2, I. Gockel3, J. Marescaux1, M. Diana1 1Research, IHU, STRASBOURG, France; 2Surgery, Department of Surgery, Hospital of Neuchâtel-Pourtalès, NEUCHÂTEL, Switzerland; 3Department of General, Digestive, and Endocrine Surgery, University Hospital of Leipzig, LEIPZIG, Germany

Background: Iatrogenic injuries may occur despite a sound expertise in surgical anatomy. Hyperspectral imaging (HSI) is an emerging optical method, combining the use of a camera system with a spectrometer. HSI analyzes optical properties of tissues and acquires 3D data sets with two spatial dimensions (x, y) and one spectral dimension (?). The data sets contain information about tissue physiology, composition, and perfusion. Those spectral features coupled with machine learning algorithms might allow for automatic tissue recognition.

Aim: Assessing the ability of an HSI-based machine learning to discriminate the hyperspectral features of different tissues during neck and abdominal surgical procedures.

Methods and procedures: Fourteen pigs underwent laparotomy (n = 6) or neck dissection (n = 8). Twenty data sets were acquired in vivo from abdominal organs and 20 from neck structures by means of a customized hyperspectral camera (Diaspective Vision, Germany). Different anatomical structures were manually outlined by a surgeon using an image manipulation software (GIMP). Each pixel contained a hyperspectral curve and each curve was composed of 100 bands (from 500 to 1000 nm with a 5 nm resolution). The curves were normalized using the standard normal variate method. A logistic regression machine learning (ML) algorithm was used to train the model to discriminate tissues, based on the HSI spectral features. The efficacy of the prediction model was tested using the k-fold (k = 10) cross-validation.

Results: A large number of tissue-related hyperspectral curves could be extracted (4675 thyroid, 9417 vagal nerve, 48546 fatty tissue, 30486 cartilage, 16001 carotid artery, 81567 muscle, 5149 carotid vein, 7148 portal vein, 22973 biliary tract, 73940 gallbladder, 1874 hepatic artery, 16712 pancreas, 2412 duodenum, 34313 abdominal adipose tissue). The algorithm used 4 min to ‘learn’ all data sets, and prediction was provided as an immediate output.

Overall, prediction accuracy was 92 and 89% for neck and abdominal structures respectively. In particular, biliary ducts could be identified with a 93% accuracy and the vagal nerve with an 89% accuracy (See Figure 1 for details).



N. Patel, A.A. Kogkas, B. Glover, A.W. Darzi, G. Mylonas Department of Surgery and Cancer, Imperial College London, LONDON, United Kingdom

Background: A gaze-controlled robotic endoscope is innovative technology with myriad potential applications in the rapidly advancing field of flexible endoscopy. Improvements to the current flexible device to allow examination of the gastrointestinal tract whilst minimising procedural discomfort and complications are desirable.

Aim: To use a gaze contingent framework to manipulate a flexible endoscope through a simulated upper gastrointestinal tract (UGIT) model.

Description: A flexible gastroscope (Karl Storz 13801 PKS) was attached to a UR5 6 axis robotic arm (Universal Robots), mounted onto a rail and placed on top of a surgical table. Two cogwheel shaped dials were 3D printed and placed onto the up/down and left/right wheels on the head of the gastroscope (Figure 1). Robotization of these controls was achieved by using two motors (DYNAMIXEL RX-24F) to steer the distal tip.

This system allows users to operate a robotised flexible endoscope using gaze control. Gaze interaction with the screen was based on a 3D gaze framework we developed with the synergy of conventional wearable eye-tracking, motion capture system and fixed in space RGB-D cameras for 3D reconstruction of the environment.

Users are able to control endoscope movements without handling the device. The distal tip of the gastroscope was controlled using eye gaze technology. The UR5 robot was used to enable shaft rotation (initiated by fixed head movements) and linear movements were triggered using a joystick handle (up for forward movement, down for endoscope withdrawal). Pause and retroflexion of the endoscope are achieved by moving the joystick left and right respectively.

Users were asked to navigate an endoscope through an UGIT model (Chamberlain group) simulating a diagnostic gastroscopy using gaze control and targeting ten points scattered through the stomach.

Results: Four expert endoscopists and one novice used gaze control to successfully navigate a gastroscope through a simulated UGIT. All were able to intubate the oesophagus and accurately locate ten targets placed in the fundus, body, antrum and pylorus of the stomach.

Conclusion: Gaze control endoscopy is a feasible concept. It allows ergonomic, user-friendly and intuitive control whilst maintaining the benefits of a flexible endoscope.



C. Gonzalez 1, F. Ouhmich2, T. Wakabayashi3, V. Agnus2, B. Gallix4, D. Mutter5, P. Pessaux5, J. Marescaux3 1Imague-Guided Surgery, IHU Strasbourg, STRASBOURG, France; 2Research & Development, IHU strasbourg, STRASBOURG, France; 3Surgery, IRCAD, STRASBOURG, France; 4Radiology, IHU strasbourg, STRASBOURG, France; 5Surgery, IHU strasbourg, STRASBOURG, France

Background: Image-guided needle biopsies and histopathological evaluation are the gold standard for the diagnosis of liver neoplasms. Most often, however, these are reserved for suspicious, but not diagnostic, situations. Radiomic may help to characterize tumor biology by correlating imaging features with relevant tumor-biology information. Features derived from radiomic analysis may provide complementary information to support clinical decisions, especially in situations where tissue analysis cannot be performed or is inconclusive.

Aim: The goal of our technology is to exploit computational capabilities for image analysis in order to identify radiomic features useful for characterizing liver lesions and to identify relevant information related to patient prognosis.

Project description: 17 patients derived from an internal database and 12 patients randomly extracted from the Cancer Archive Liver Dataset were included in this study. 56 lesions were extracted from those volumes using expert annotations (31 secondary vs 25 primary; 34 well differentiated vs 22 non-well differentiated). Lesions were then split into training and testing sets. First order statistical features were computed and a Lasso regression step was performed to reduce the number of features. Both logistic regression and random forest models were built using cross-validation to predict the target classes on the test set.

Preliminary results: Only 2 features namely the Energy and the Volume of the lesion were sufficient, when combined in either model, to predict the differentiation grade on the test set with an F1-Score of 0.74(± 0.07). We are currently working on the addition of higher order statistical features to the analysis in order to differentiate primary from metastatic tumors and identify complementary features that may assist clinical decisions in patients with inconclusive hepatic lesions.



E.J. Barzola Navarro 1, A. Glagolieva2, V. Galvez3, J. Salas4 1Digestive Surgery, Universidad de Extremadura, BADAJOZ, Spain; 2Surgery, PL Shupyk National Medical Academy, KIEV, Ukraine; 3Chemistry, Universidad de Extremadura, BADAJOZ, Spain; 4Technology, Universidad de Extremadura, BADAJOZ, Spain

Objective of the technology or deviceIdeally, the use of medical simulators could provide trainees with initial background information about indications for procedures, endoscopic technique, and early hands-on training experience that could shorten the initial critical learning curve. Rationale for using ex vivo models is that in the beginning of the learning curve, the most important issue is having an initial exposure to the basic movements and maneuvers. Our objective of is to create a stomach model from renewable polymer, which would closely simulate normal human stomach with gastric pathology for endoscopic diagnostic or interventional skill acquisition/evaluation.

Description of the technology and method of its use or application Stomach model is based in several steps; the first one is in the in-silicodesign of the overall shape, after that we 3D print the positive two halves of it. The interior detail is obtained shaping the 3d printer parts with ceramic putty. Once concluded, this elaborated part will serve as a template in order to build injection bleeding moulds. In the injection bleeding moulding a mesh is placed between layers in order to provide structural attachment points as stiches or several pathological models that will be incorporated after the casting process. We have developed for these instance polyp moulds, fistulae structures in order to attach endoscopic clamps. The two halves are closed once the pathological models are placed inside via a thermic-fusing and stitching creating a leak proof stomach model.

Preliminary results if available: Our models were evaluated by 8 international experts in IRCAR/IHU France in Interventional Endoscopy Course and were favorable accepting for next trails in these prestigious institutions.

Conclusions: Future directionsA new endoscopic training model of stomach was made and will be evaluated and validated for feasibility in mastering diagnostic and interventional endoscopic skills.

Clinical trials will be necessary to compare the ability of the simulator to perform training compared with traditional methods of training in endoscopic procedures.



Z. Li1, C.Z. Song1, X. Ma2, P.W.Y. Chiu 1 1Surgery, The Chinese University of Hong Kong, HONG KONG; 2Chow Yuk Ho Technology Centre for Innovative Medicine, The Chinese University of Hong Kong, HONG KONG

Background: Endoscopes are the eye of surgeons in minimally invasive surgery (MIS). Conventional endoscopes are mostly chopstick-like and are steered by the assistant. This limits the field of view and results in issues such as endoscope-instrument fencing, surgeon-assistant coordination. Existing robotic endoscope holder enables solo-surgery, however endoscope remains blocking the instrument movement and impairs the operational safety. Flexible endoscope such as the Endoeye provides angulation at the tip and could enlarge the field of view. However, its steering the view is much more complex compared to the rigid endoscope.

Aim: To provide an intuitive robotic flexible endoscope with enhanced safety.

Project description: In this work, we present a robotic flexible endoscope for MIS with enhanced safety. In the proof-of-concept system, it contains a flexible endoscope module and a robot manipulator. The endoscope contains a proximal rigid shaft and a distal flexible bending section. It is installed onto the patient side manipulator (PSM) of the da Vinci Research Kit (DVRK). Visual servoing is adopted to achieve autonomous instruments tracking. During the tracking process, movements of the manipulator as well as the endoscope are minimized to save space for the operation and avoid instrument-endoscope fencing. The endoscope could also be controlled by the surgeon. A foot pedal is used to switch between the Tracking-Mode and Control-Mode.

Preliminary results: A prototype was developed and tested experimentally. In tracking a volume of 200*200*100 mm3, the spaces required by the flexible endoscope are 15.55% (inside the trocar) and 9.83% (outside the trocar) of that occupied by the rigid endoscope. Evaluation with the FLS tasks involved 10 subjects. All of the participants completed the tasks under the Tracking-Mode without failure. In the ex-vivo test with porcine stomach, the endoscope successfully guided the detection, dissection and knotting autonomously.



B. Seeliger 1, A.H. Ashoka2, V. Agnus1, M. Barberio1, A. Picchetto3, B. Andreiuk2, S.H. Kong4, A.S. Klymchenko2, M. Diana1 1Institute of Image-Guided Surgery, IHU-Strasbourg, STRASBOURG, France; 2Laboratory of Bioimaging and Pathologies, UMR 7021 CNRS, Faculty of Pharmacy, University of Strasbourg, STRASBOURG, France; 3Department of General Surgery, Surgical Specialties and Organ Transplantation, Sapienza University of Rome, ROME, Italy; 4Department of Surgery, Seoul National University Hospital, SEOUL, Korea

Background: Fluorescence imaging allows to visualize deep-seated anatomical structures, using a deeper tissue penetration of near-infrared (NIR) compared to visible light. The most commonly used fluorescent substance, Indocyanine Green (ICG), is not naturally excreted by the urinary system and requires retrograde stent placement and injection. Lighted catheters have been proposed to help visualise the ureter. Fluorescent dye-coated ureteral catheters could well represent a more effective and less expensive solution. ICG is unsuitable for coating materials.

Aim: To develop a stable fluorescent coating for catheters to be used intraoperatively, working in the same NIR window as ICG, to facilitate its use with clinically available systems.

Project description: The coating was developed based on Poly(methyl methacrylate) (PMMA), a biocompatible polymer, and on specifically designed fluorescent dyes exhibiting ICG-like optical properties.

Three NIR dyes (substances A, B, and C) were tested in order to find the optimal one, in terms of fluorescence signal intensity, and were compared to ICG in a polymer form and to an ICG-based reference card (Green Balance™). The fluorescent coating was applied onto 3 common ureteral stent materials: hydrophilic-coated Ultrathane®, silicone-coated latex, and PVC. The coating process involved 3 cycles of immersion into the respective dyes blended in PMMA polymer (ICG, substances A, B, and C), followed by a drying phase. The various tubes were partly inserted into a porcine ureter, next to the ICG-based reference card. Images were taken in White Light and NIR modes using the D-Light P camera system (KARL STORZ), at a fixed camera-to-target distance. The fluorescence signal intensity was measured for the different regions of interest (each material/coating combination inside and outside of the ureter, reference card) using proprietary software and normalised against the reference card.

Preliminary results: The signal intensity was significantly higher for all new substances as compared to ICG. Substance A showed the strongest fluorescence signal intensity among the tested coatings in all tested conditions and materials and was identified as the ideal candidate to undergo further evaluation and in vivo testing.



S.G. Lim, L. Sosa-Valencia, L. Swanstrom Institute for Image Guided Surgery, IHU-Strasbourg, STRASBOURG, France

Background: Endoscopic resection(ER) of early gastric cancers provides tremendous patient advantages. However, post-resection findings of deeper sub-mucosal(SM) and/or lympho-vascular invasion can necessitate a second, surgical intervention. We propose that pre-resection evaluation of the submucosal architecture under the tumour can provide critical information for staging and operative planning. We evaluate three techniques to assess the submucosal architecture underlying the gastric mucosa in a pig model.

Aim: To evaluate three needle-based methods of evaluating the SM before ER.

Project Description: 6 acute pigs were used. A simulation of sub-mucosal tumours (endoscopically and EUS visible bleb) by injecting the SM with 20 cc of undyed NaC. A linear EUS was use for all procedures. The tumours were marked and labelled according to geography.

Methodology: After creating the tumours, anterior lesions were evaluated using the following 19G needle-based modalities: Confocal microscopy(CM) using the through-the-needle Cellvizio (Mauna-Kea) system; Mini-biopsy(MB) using the micro-biopsy forceps Moray (US Endoscopy) and Fine-needle biopsy(FNB).

Results: 18 CM examinations were video recorded in all A positions. Submucosal vascular visualisation was possible in all cases, excellent in 17/18. MB was performed in 18 lesions with a total of 2 biopsies obtained from each lesion (total = 36). FNB was performed once in the anterior lesions and twice in the posterior lesions with different needle brands. Therefore, there was a total of 54 biopsies collected. 2 passes were performed in each biopsy (total = 108). Each pass constituted 20-25 insertion/withdrawal movements combined with fanning, slow pull technique, no suction and suction (10-20 cc air negative pressure) to collect the material. All material were sent to an animal anatomo-pathologist blinded to the acquisition method. Mean time of confocal examination was 15 min 8sec (6’02’’-30’59’’). MBtook a mean time of 5 min and FNB was a mean of 10 min for each biopsy. CM identified different patterns of vessels in relation to the probe position (superficial/reticular, middle cross-roads or deep/longitudinal). Conclusion: EUS-FNB, CM and MB are three potential methods to assess the sub-mucosal space underlying the gastric mucosa. CM offered the most architectural information but required more time to perform. These method’s may have a role in better staging patients for appropriate ER.



A. Przedlacka 1, S. Cox1, N. Khan2, P. Paris1, F. Bello3, C. Kontovounisios1 1Department of Surgery and Cancer, Imperial College London, LONDON, United Kingdom; 2Radiology, Chelsea and Westminster Hospital, LONDON, United Kingdom; 3Centre for Engagement and Simulation Science, Imperial College London, LONDON, United Kingdom

Background: The overall and disease-free survival of patients with rectal cancer is dependant on its staging, and adequate selection of the treatment strategy. MRI has a proven efficacy in rectal cancer local staging and recognition of the adverse prognostic features. However, it can be difficult to utilise it as a navigation tool for surgeons, as it represents a complex three-dimensional pelvic space with a series of individual two-dimensional images. 3D image reconstruction has been successfully adopted in other surgical fields to overcome these limitations.

Aim: Our primary aim is to develop a bespoke automated generation of patient-specific 3D pelvic models, which will improve surgical planning and navigation, patient interaction and surgical education. True-size, rotatable 3D models will offer a more realistic three-dimensional representation of the surgical space and its complex relationships, allowing for a more confident surgical rehearsal and potentially better utilisation of minimally invasive techniques in rectal cancer management. Our secondary aim is to develop a large multipurpose database of the 3D models of male and female pelvis in health and in the disease.

Project description: Our multidisciplinary team consists of colorectal surgeons, radiologists specialising in pelvic MRI imaging and computer scientists. Virtual 3D pelvic models are generated based on standard 2D DICOM MRI images routinely used for rectal cancer staging, which guarantees the high fidelity of cancer delineation. Segmentation of the pelvic anatomy is performed with the use of ITK-SNAP, an open-access, multi-platform software. Machine learning technology is then employed to automate the 3D model generation, making it time-efficient, allowing for its clinical application.

Preliminary results: In the initial stage, using the manual segmentation, we have created ten models of normal male and female pelvic anatomy. A good inter-rater agreement level was found, which proves reproducibility of the approach applied. Various machine learning algorithms are being explored to fully automate the process of 3D model generation, which will allow for their use in clinical practice and in development of the 3D colorectal database. The technology will be further implemented in creation of dynamic models of functional pelvic floor disorders.



R. Watanabe 1, M. Barberio2, A. Lapergola2, A. Klymchenko2, L. Guerriero2, S. Kanaji3, M. Pizzicann2, B. Seeliger2, Y. Saida1, H. Kaneko4, M. Worreth5, A. Saadi5, J. Marescaux3, M. Diana2 1Surgery, Toho University Ohashi Medical Center, TOKYO, Japan; 2Institute of Image-Guided Surgery, IHU-Strasbourg, STRASBOURG, France; 3Research Institute against Digestive Cancer, IRCAD, STRASBOURG, France; 4Surgery, Toho University Omori Medical Center, TOKYO, Japan; 5Surgery, Neuchâtel Hospital, NEUCHÂTEL, Switzerland

Background: Laparoscopic gastrojejunostomies are time-consuming and require a specific training. Alternatively, sutureless anastomosis can be achieved by means of endoscopically delivered magnetic rings.

Objective of the study: Assessing the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using magnets coated with a fluorescent biocompatible polymer.

Methods and Procedures: Four pigs (2 acute, 2 survival models) and one cadaver were included in this study. The anastomotic device was composed of two magnetic rings (25x8x6 mm; attraction force 30 Newton), each one attached to a 75 cm long thread. The distal ring was inserted endoscopically into the first duodenum, and the extremity of the thread was clipped to the gastric mucosa. Twenty-four hours later, a two-port laparoscopy (12 mm, 5 mm) was performed, using a Near-Infrared (NIR) laparoscope (D-Light-P; Karl Storz). The magnet’s position in the jejunum was detected thanks to the transluminal fluorescence of the dye. Magnetic interaction with the metallic tip of the laparoscopic grasper allowed to catch the ring and bring the bowel loop to the future anastomotic site on the gastric wall. Simultaneously, the proximal magnet was delivered to the gastroesophageal junction using a flexible endoscope. The magnet was carefully advanced into the stomach allowing precise connection with the distal ring. In one cadaver the procedure was repeated. The sole variation was that, in order to reach the second jejunal loop, the distal magnet was placed using a gastroscope inserted through a transgastric port.

In two acute animals, the distal magnetic ring was introduced into the jejunum via an enterotomy. The anastomotic procedure (from the distal magnet detection via fluorescence to the magnetic connection using a hybrid approach) was reiterated 40 times. Survival animals were followed-up for 10 days and underwent control endoscopies and CT-scans.

Results: The procedure was easy to standardize and reproducible, with a mean anastomotic procedure time of 2.62 ± 1.42 min. There were no technical problems and magnetic connection could be precisely directed in all cases, at both the anterior and posterior gastric wall. No complications occurred during the survival period and the anastomoses were patent by day 5. Transluminal fluorescence allowed for a rapid detection of the magnet.



G. Ciuti 1, A. Firrincieli1, F. Bianchi1, N. Gabrieli2, F.P. Falotico2, J. Ortega1, M. Verra3, M. Bonino3, S. Arolfo3, E. Mazomenos4, P. Brandao4, D. Stoyanov4, A. Koulaouzidis5, S. Schostek6, M.O. Schurr6, A. Menciassi1, C.M. Oddo1, A. Arezzo7, P. Dario1 1The BioRobotics Institute, Scuola Superiore Sant’Anna, PONTEDERA, Italy; 2Mediate Medical, Mediate Srl, PISA, Italy; 3Molinette Hospital, University of Turin, TURIN, Italy; 4Computer Science, University College of London, LONDON, United Kingdom; 5UEDIN, University of Edinburgh, EDINBURGH, United Kingdom; 6OVE, Ovesco Endoscopy AG, TUBINGEN, Germany; 7Molinette hospital, University of Turin, TURIN, Italy

Colorectal cancer is the fourth most common cancer in high-income countries counting > 700.000 deaths worldwide. Survival rate reaches 94% in case of early diagnosis, falling down to 11% in case of advanced stage. Conventional colonoscopy screening is limited by invasiveness, pain and often need of sedation. Wireless capsule endoscopy enables inspection without discomfort, but passive locomotion often leads to incomplete and/or false negative results.

The European Endoo Project (Grant Agreement 688592) aims to develop a novel system that overcomes most of the drawbacks of conventional colonoscopy, maintaining accurate and reliable diagnosis and therapy. The system is composed of an active robotic platform that magnetically drives a soft-tethered capsule; magnetic guidance is achieved through the magnetic localization of the capsule in combination with a closed-loop control that maintains an optimal and safe link between the capsule and the magnetic end-effector. A stereoscopic camera is integrated in the capsule for enhanced diagnosis though 3D reconstruction and automated detection of lesions/pathologies.

The different modules of the Endoo medical platform are illustrated in the figures. The robotic guidance systemconsists of an anthropomorphic manipulator that controls the capsule through an external permanent magnet. The robot, positioned on a dedicated trolley, is equipped with sensors for performing safe human-robot collaboration. The medical workstationincorporates: screens, buttons and pedals for visualization and command initiation, a joystick for system teleoperation and a back-end for fluidic control and data communication.

The soft-tethered capsuleembeds an internal permanent magnet, magnetic sensors, an accelerometer, white and infrared illumination and an HD stereoscopic vision system with two wide-angle customized optics. A controller serves as the main control unitfor performing real-time communication and closed-loop control of the robot, localization system, capsule and physician commands.

The synergistic cooperation of academic, industrial and clinical partners within the project allowed to develop and validate the system in in-vitro </i> , ex-vivoand preliminary cadaver sessions, performing comparisons with state-of-the-art commercial colonoscopes. In conclusion, the Endoo medical platform provides: reduced procedural pressures, user-friendly procedures, similar functionalities and performances of commercial devices, comparable procedural times and considerably lower costs with a new painless approach.



D.N. Panchenkov 1, D.D. Klimov2, A.A. Nechunaev3, A.S. Levin4, O.V. Zairatyans5, A.A. Vorotnikov4, Yu.V. Poduraev4, L.S. Prokhorenko4, O.V. Levchenko6, V.V. Krylov6, O.O. Yanushevich7 1Minimally Invasive Surgery, A.I. Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 2Medical Robotics Digital Technologies, A.I. Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 3Endoscopic Surgery, A.I. Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 4Robotics and Mechanotronics, Moscow State Technjlogy University STANKIN, MOSCOW, Russia; 5Pathology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 6Clinical Medical Center, A.I. Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia; 7Paradontology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, MOSCOW, Russia

Background: This study is aimed at the comparison of the process of manual and robotic-assisted positioning of the electrode performing radio-frequency ablation with the usage of multifunctional robot-assisted surgical platform. under the control of the surgical navigation system. The main hypothesis of this experiment was that the use of a collaborative manipulator will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. We also check the stability of the electrode’s velocity during insertion and consider some advantages in ergonomics using the robotic manipulator.

Methods: Sphere-shaped tumor phantoms measuring 8 mm in diameter were filled with contrast and inserted in cow livers. 10 livers were used for the robotic experiment and an equal quantity for manual. The livers were encased in silicone phantoms. Analysis of CT data gave the opportunity to find the entry and the target point for each tumor phantom. This data was loaded into the surgical navigation system that was used to track and record the position of the RF-electrode during the operation for further analysis.

Results: Standard deviation of points from the programmed linear trajectory totaled in the average 0.3 mm for the robotic experiment and 2.33 mm for the manual operation with a maximum deviation of 0.55 mm and 7.99 mm respectively. Standard deviation from the target point was 2.69 mm for the collaborative method and 2.49 mm for manual method. The average velocity was 2.97 mm/s for the manipulator and 3.12 mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was 0.66 mm/s and 3.05 mm/s respectively.Thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. Surgeons also noticed advantages in ergonomics performing the procedure using the manipulator.

Conclusions: This experiment was produced as part of the work on the developing of the robotic multifunctional surgical complex. We can confirm the potential advantages of using robotic manipulators for minimally invasive surgery in case of collaborative practice for cancer treatment.



R.R. Postema 1, L. van Gastel1, S.F. Hardon2, T. Horeman3, H.J. Bonjer1 1Surgery VUMC, Amsterdam University Medical Centers, AMSTERDAM, The Netherlands; 2Surgery VUMC, Delft University of Technology, DELFT, The Netherlands; 3Biomechanical Engineering, Delft University of Technology, DELFT, The Netherlands

Background and aims: Laparoscopy has reduced tactile feedback compared to open surgery. In neuropsychological literature there is increasing evidence that visual and haptic information converge to form a mental representation of an object. Through the combination of these inputs, this representation is believed to be more refined and robust. We investigated whether tactile exploration of a lifelike anatomical object before executing a laparoscopic action on this object in a laparoscopic box trainer improves performance of this action.

Description: A randomized prospective cohort study with two groups (A + B) of ten laparoscopically naïve medical students was conducted. We compared the groups for baseline characteristics and performance, using a basic laparoscopic task (post and sleeve). To investigate the effect of haptic exploration, students performed ten repetitions of a laparoscopic needle action on a lifelike silicone caecum model (Applied Medical, Rancho Santa Margerita, USA). Group A did a pre-test visual exploration of the model. In group B manual exploration of the anatomical model was added to the visual exploration before executing the task. The box trainer was equipped with the ForcesenseTm (Medishield, Delft, The Netherlands) system for skill assessment using objective force, motion and time parameters.

Results: Baseline characteristics and—laparoscopic performance were comparable (p > 0,05). Performances of 200 trials on the anatomical model were captured and parameter outcomes were compared between groups. Significantly less force (maximal force, maximal impulse, mean force and force volume) was exerted by the ‘touch’ group (p < 0.000) (Fig. 1). This group also completed the task with less distance travelled by the instruments (p < 0,003). There was no significant difference in time needed to complete the task (p = 0,695).

Conclusion: This study showed that, when performing a laparoscopic task on an anatomical model, pre-task haptic exploration of the model results in the use of significantly less force and less movement. Adding haptic exploration to a laparoscopic training curriculum could therefore result in more efficient and more refined learning of laparoscopic actions. This, in turn, could lead to better, quicker and safer performance of laparoscopic operations.



M. Okocha, N.J. Browning, T. El Jichi, S. Shafiq, H. Sumrien General surgery, NHS, BRISTOL, United Kingdom

Aim: To demonstrate the relation between smoking and length of hospital stay in Enhanced Recovery after Surgery (ERAS) patients, who underwent elective major colorectal surgery in a tertiary referral centre—North Bristol NHS Trust—(NBT).


The NBT ERAS programme is well established and all patients who undergo colorectal resection are included. Smoking increases risk of poor postoperative outcomes, general morbidity and wound complications. NBT is a smoke-free trust, and it became noticeable that smokers mobilise earlier after surgery to get to smoking zones. Previous studies showed that less than 7.5% of smokers stop smoking in the perioperative period.

Methods: Prospective review of data collected from ERAS patients who had elective colorectal resection between January 2017 and January 2018. Outcomes collected included, type of surgery, open or laparoscopic ± conversion, and length of hospital stay. Smoker and non-smoker groups were compared in terms of post-operative length of stay.

Results: Between January 2017 and January 2018, we performed 200 major colorectal resections, of these 40% were on Female patients (82) (males 118). Procedures included 51 right hemicolectomies (including extended), 70 anterior resections/TME, 10 APER, 14 Hartmann’s reversals and 55 Left Hemicolectomies, Transverse colectomies, subtotal colectomies and segmental colectomies. 140 (69%) cases were laparoscopic, 41 (20%) open and 21 (14%) were laparoscopic converted to open. Mean hospital stay 8 days, median 5 days, re-admission rate was 15.3% and SSI was 8.1%.

Mean age of smokers was 62, range 30–86. Mean age of non-smokers was 66, range (19–93).

All smokers were advised to stop smoking prior to surgery during enrolment on our ERAS programme. Of the 200 patients 49 were smokers, 148 non-smokers and 3 patients’ smoking status was unknown. Of the smokers 4% (2) ceased smoking with advice. Mean length of hospital stay for smokers was 6.81 and non-smokers was 7.13 days.

Conclusion: Smokers remain a challenging group in terms of compliance and the majority of patients who are advised to stop smoking prior to surgery did not . Although smokers seemed to mobilise early postoperatively, that did not translate into a reduction of hospital stay.



M. Fried 1, V. Reddy2, R. Rosen3, N. Kipshidze4, N. Kipshidze5 1Center for Treatment of Obesity and Metabolic Disorders, OB klinika, PRAGUE, Czech Republic; 2Mount Sinai Hospital, New York, USA; 3Lenox Hill Hospital, New York, USA; 4New York University, New York, USA; 5New York Cardiovascular Research, New York, USA

Background: Obesity is growing epidemic, associated with adverse cardiovascular and metabolic conditions. Number of weight loss strategies are unsuccessful and/or accompanied with risks. Ghrelin is a orexigenic hormone. Catheter-directed left Gastric Artery Bariatric Embolization (GABE) causes a reduction in plasma ghrelin levels and weight loss as demonstrated in animal models and several pilot clinical studies.

Aim: To evaluate the efficacy and safety of the Endobar Lamina embolization system (ELES) for the treatment of obesity.

Project description: 44 obese patients, BMI 35.0–55.0 kg/m2 were randomized to blinded treatment with GABE (n = 22) or sham procedure (n = 22). GABE was performed using ELES (Endobar Solutions, LLC, Orangeburg, NY, USA) and BeadBlock Embolic Bead 300–500 mm microspheres (Biocompatibles Limited, UK). Esophagogastroscopy was performed before GABE and 1-week post-procedure assessing gastric abnormalities. Weight and fasting plasma ghrelin were obtained at baseline, 1-, 3-, 6- and 12-months post-index procedure. After 6 months, the Sham group was unblinded and received GABE. Both GABE and Sham crossover to GABE groups were followed for 12 months and received Lifestyle Therapy (behavioral-diet education).

Preliminary results: GABE was successful in all patients with no serious complications. Significant, progressive weight loss was observed at 6 and maintained at 12 months. Ghrelin in GABE group decreased by 22% (67.91 pg/ml) compared to baseline and 12 months levels. Weight-loss was approximately 6.5% greater in the GABE group versus sham at 6 months (Table 1).

ITT = Intent-to-treat, PP = Per-protocol

Analysis preformed using independent-sample t-test and Paired-sample t-test

Conclusions: GABE using ELES is safe, accompanied by significant and so far maintainable weight loss. GABE using the ELES demonstrated a reduction in ghrelin levels.

O206—UPPER GI—Gastric cancer


R. Van Hillegersberg 1, A. Van der Veen2, H.J.F. Brenkman2, M.F.J. Seesing2, L. Haverkamp2, M.D.P. Luyer3, G.A.P. Nieuwenhuijzen3, J.H.M.B. Stoot4, K.W.E. Hulsewé4, B.P.L. Wijnhoven5, W.O. De Steur6, E.A. Kouwenhoven7, E.B. Wassenaar8, W. Draaisma9, S.S. Gisbertz10, D.L. Van der Peet11, J.P. Ruurda2, . LOGICA study group12 1Department of Gastrointestinal Surgical Oncology, University Medical Center Utrecht, UTRECHT, The Netherlands; 2Surgery, University Medical Center Utrecht, UTRECHT, The Netherlands; 3Surgery, Catharina Hospital, EINDHOVEN, The Netherlands; 4Surgery, Zuyderland Medical Center, HEERLEN AND SITTARD-GELEEN, The Netherlands; 5Surgery, Erasmus University Medical Center, ROTTERDAM, The Netherlands; 6Surgery, Leiden University Medical Center, LEIDEN, The Netherlands; 7Surgery, ZGT Hospitals, ALMELO, The Netherlands; 8Surgery, Gelre Ziekenhuizen, APELDOORN, The Netherlands; 9Surgery, Meander Medical Center, AMERSFOORT, The Netherlands; 10Surgery, Academic Medical Center and Cancer Center, AMSTERDAM, The Netherlands; 11Surgery, VU University Medical Center, AMSTERDAM, The Netherlands; 12The Netherlands

Introduction: Open gastrectomy is the preferred surgical approach for gastric cancer worldwide. This procedure is associated with considerable morbidity. Meta-analyses have shown an advantage in short-term outcomes of laparoscopic gastrectomy compared to open procedures, with similar oncologic outcomes. However, the included series are mostly from Asia with early gastric cancer. It is unclear whether these results can be extrapolated to the Western population with mostly advanced gastric cancer. In this randomized controlled multicenter trial from the Netherlands, we assessed the outcomes of laparoscopic versus open gastrectomy.

Methods: Between 2015 and 2018, patients with resectable (cT1-4a, N0-3b, M0) gastric adenocarcinoma were randomly assigned to either laparoscopic (105 patients) or open (105 patients) gastrectomy, in 10 participating centers in the Netherlands. Inclusion criteria were age = 18 years, European Clinical Oncology Group performance status 0, 1 or 2 and informed consent. The primary outcome was postoperative hospital stay (days). Secondary outcome were postoperative morbidity and mortality, oncologic outcome, readmissions, quality of life and cost-effectiveness.

Results and conclusion: This is a late breaking abstract. The data are not yet mature at the moment of writing this abstract.



M. Penna 1, R. Hompes2, N. Mortensen3, P.P. Tekkis4, G.B. Hanna5 1Academic Surgery, Imperial College London, LONDON, United Kingdom; 2Colorectal surgery, Amsterdam UMC, AMSTERDAM, The Netherlands; 3Colorectal surgery, University of Oxford, OXFORD, Uganda; 4Colorectal surgery, Imperial College London, LONDON, United Kingdom; 5Cancer and Surgery, Imperial College London, LONDON, United Kingdom

Aims: Transanal total mesorectal excision (TaTME) is the latest colorectal approach that continues to be in the spotlight. This study aims to describe the technique in depth by identifying and understanding technical advantages, errors and adverse events.

Methods: Detailed video analysis using Observational Clinical Human Reliability Analysis (OCHRA) was completed on 100 clinical TaTME cases performed by 27 international surgeons. Error frequency and error pathways leading to adverse events were described. TaTME expert surgeons were interviewed and engaged in a workshop to elicit error-reducing mechanisms.

Results: Overall technical errors and adverse events per procedure on average occurred 49 ± 32.9 (range 6-–194) and 9 ± 6.1 (range 1–45) times respectively. Inadequate insufflation and poor camera optics were the most frequent set-up problems. Instrument handling errors consisted most commonly of excessive grasper movement during the pursestring phase (321 times total), inappropriate force applied (79 times) with the energy device during the rectotomy, inappropriate force with the grasper (74 times) and excessive movement with the energy device (117 times) during TME dissection. Incorrect dissection planes were created during TME dissection mostly due to insufficient retraction (127 times) which didn’t allow adequate exposure of the tissue planes. The most frequently occurring consequence was bleeding (Mean: 6 times per procedure). Rectal perforation (7 cases), vaginal wall injury (4 cases), and prostatic injury (7 cases) were also recorded. Adverse events regularly occurred as a result of poor set-up/exposure, inappropriate retraction and/or instrument movement and incorrect plane surgery. Error-reducing mechanisms and ‘technical tips’ describe specific steps and actions, both set-up/equipment-related and technique-related, that aim to prevent errors from occurring and avoid adverse consequences. OCHRA and individual feedback with error-reducing mechanisms developed by this study have been implemented into the national training programme for TaTME.

Conclusion: TaTME is an advanced complex procedure during which technical errors and their consequences are not infrequent. TaTME requires knowledge of anatomy ‘bottom-up’, familiarity with its specialised equipment and technical skill working in a narrow space. Appropriate structured training and mentorship are therefore recommended.



G. Maggi 1, P. De Nardi1, R. Maggiore1, L. Boni1, E. Cassinotti1, U. Fumagalli1, M. Gardani1, U. Elmore2, A. Vignali2, R. Rosati2 1San Raffaele Hospital, MILAN, Italy; 2Gastrointestinal Surgery Unit, San Raffaele Hospital, MILAN, Italy

Objective: Insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. ICG has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections and thus possibly reducing the leak rate. Objective of this study is to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using intraoperative indocyanine-green dye (ICG) angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis.

Methods: This randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative ICG or to subjective visual evaluation of the bowel perfusion without ICG ( NCT02662946). The primary aim was to assess whether ICG angiography could lead to a reduction in anastomotic leak rate. Secondary outcomes were possible changes in the surgical strategy and postoperative morbidity.

Results: After randomization, 12 patients were excluded. Accordingly, 240 patients were included in the analysis; 118 in the study group, and 122 in the control group. ICG angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection, in 13 cases (11%). An anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.).

Conclusion: Intraoperative ICG fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. This method led to further proximal bowel resection in 13 cases, however its role in reducing anastomotic leak rate should be studied in further research.



G. Bilande 1, M. Mukans2, E. Liepins3, O. Kozlovskis4, J. Zarinovs5, I. Troickis3 1Department of Surgery, Jurmala hospital, JURMALA, Latvia; 2Surgery, Aiwa clinic, RIGA, Latvia; 3Surgery, Jurmala hospital, JURMALA, Latvia; 4Surgery, Sigulda hospital, SIGULDA, Latvia; 5Surgery, Riga 1st hospital, RIGA, Latvia

Aims: The objective of the current study was to evaluate lifestyle habits and weight loss experience of obese patients prior to bariatric surgery.

Methods: This is 1 year quantitative cross-sectional study that was carried out in four clinics in Latvia. The subjects of this study were patients who applied for bariatric surgery and their participation in questionnaire was voluntary and random.

Results: There were 72 individuals (63 woman and 9 man; age 30–49 years). Maximum lifetime weight range was 132–96 kg with average patient BMI 37.6 kg/m2. At least 1 co-morbity was admitted by 27% of patients. 54.8% of patients are eating regular breakfast. Most of subjects became obese in adolescence (26%) or in adulthood (37%). Only 14 patients succeeded to (19.2%) reduce weight prior surgery; 20 subjects (27.4%) weight was relatively stable, but rest patient’s (53.3%) weight increased. 98% of all patients had tried different weight loss methods before. There is linkage between patient’s age and food consumption—subjects aged under 37 years regularly overeat (61.3%), but elder ones are more likely to have regular meals (72.2%). There is lack of physical activity—only 30.1% of patients are active more than 40 min a day. Over 70% of patients spend at least 4 h per day in sitting position.

Conclusions: The results highlight that all patients unsuccessfully tried to reduce weight by other methods before bariatric surgery. The reason for poor preparation was irregular meals, breakfast avoidance, low physical activity and there also was impact of patient’s age. Additional research and data are needed to explore how regular meals, adequate physical activity, combined with other weight reducing methods could give better results to prepare for bariatric surgery.




M. Pizzicannella 1, C. Fiorillo1, P. Mascagni1, M. Vix2, D. Kadoche2, D. Mutter2, J. Marescaux3, S. Perretta1 1IHU, STRASBOURG, France; 2Digestive and Endocrine Surgery, Nouvel Hopital Civil, University of Strasbourg, STRASBOURG, France; 3IRCAD Research Institute against Digestive Cancer, STRASBOURG, France

Endoscopic sleeve gastroplasty (ESG) is a promising endoscopic bariatric procedure carried out with the application of transmural sutures resulting in a gastric reduction and gastric shortening. Sutures are placed in U shape fashion, from the incisura to the fundus, which is preserved, using an over the endoscope suturing platform (OverStitch, Apollo Endosurgery, Austin, Texas, USA). The choice of right lankmarks for suturing the gastric wall is extremely important for the efficacy and safety of the procedure. Flexible endoscopy suffers from little anatomical reference points. Correct spatial relation to precisely target the insertion of the helix device used for retraction and correct orientation of the full thickhness tissue bite require a good undrestanding of the anatomy of the stomach and sourrounding organs including vascular structures that could be inadvertently injured (left lobe of the liver, gallbladder, spleen, short gastric vessels, pancreas, transverse colon). Surgeons by training can ‘see’ the anatomy beyond the gastric wall and undrestand whether they work in a safe layer or whether an underlying structure should be spared.

This video illustrates all the potential risks realted with a wrong chioce of endoscopic landmarks when performing ESG with respect to gastric and abdominal anatomy.



S.H. ChoiJ.W. Lee, J.Y. Jang Surgery, Bundang CHA Medical Center, SEONGNAM-SI, Korea

Introduction: Central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are technically demanding procedures in minimally invasive approach because of difficult expoure and extensive parenchymal transection planes. With limited robotic instruments including absence of CUSA, these procedures have been rarely perfomed by robotic approach.

Method: Consecutive robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy were performed. Patients were all males and were 67, 71, and 41-years-old, respectively. Pathologic diagnoses were all hepatocellular carcinomas of each 4.4, 4.2, and 3.2 cm diameter. Operative settings were identical for the three kinds of procedure. The patients were placed in supine with a reverse Trendelenburg and right side elevation. Umbilical 12-mm camera port, three 8-mm ports and additional 12-mm assistant port were used. Glissonian approach and ICG fluorescence image clearly demarcated the resection planes. Parenchymal transection was performed using the Maryland bipolar dissector and harmonic scalpel. The rubber band self-retraction method and third arm of robot system helped for stable and excellent exposure of surgical planes

Result: There were no conversions to laparoscopic or open surgery. The operative time was 320, 330, and 290 min and estimated intraoperative blood loss was 200, 330, and 250 ml. The pathologic surgical margin was 2.5, 0.5, and 3.6 cm. The length of stay after surgery was 7, 8, and 6 days and there were no postoperative complications.

Conclusion: Robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are still demanding procedures with long operative time. However, these procedures could be performed safely in regard to short-term perioperative outcomes. Robot surgical system provided several benefits for anatomical hepatectomies including a stable and excellent operative field and clear surgical planes.

V003—HERNIA-ADHESIONS—Abdominal wall hernia


N. García Fernández, P. Garcia Muñoz, R.E. Licardie Bolaños 2, I. Alarcon del Agua, J. Tinoco Gonzalez, L. Tallon Aguilar, J. Padillo Ruiz, S. Morales Conde, Cirugía General Y Del Aparato Digestivo, Hospital Universitario Virgen Del Rocio, SEVILLA, Spain

Suprapubic hernias (less than 5 cm above the pubic arch in the midline) require important anatomical knowledge because of complexity of their repair and low incidence, by approximately 2% of all hernias. The problem to repair this type of hernias is that inferior margin of the defect is very close to pubic symphysis, consequently, mesh overlap is often inadequate. Treatment of suprapubic hernias is controversial because of limited evidence in the literatura.

This video shows the case of a 40-year-old female patient with suprapubic hernia with a defect of 3x3 cm. We performed a laparoscopic repair with a bilateral peritoneal flap of the groin region (as it is perfromed during TAPP) for proper view of the pubic symphysis, Cooper’s ligaments, epigastric and major vessels, nerves and meticulous dissection the space of Retzius. The defect was repaired by reconstructing the middle line with a running sutures. Subsequently, titanium helical tacks were used to fix the mesh to the pubis and Cooper and following the double-crown technique having special attention when fixing the mesh near to inguinal chanal, due to the possibility of causing chronic pain. The peritoneal flap was fixed over the mesh with abdsorbable fixation devices and seal with fibrin glue.

Laparoscopic repair of suprapubic hernias can be considered as the first option in treatment, because it endeavors to join the advantages of a minimally invasive approach and it is associated to low recurrence. The main advantages are that allows a proper visualization the anatomy and a proper fixation of the mesh.

V004—UPPER GI—Esophageal cancer


T. Kamei, Y. Taniyama, H. Okamoto Surgery, Tohoku University Hospital, SENDAI, Japan

Background and aim: Thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. We evaluate our cases who undergone the thoracoscopic esophagectomy and consider the future prospective of this operation.Transient recurrent laryngeal nerve palsy after lymphadenectomy in this surgery is not rare and induces not only hoarseness but also aspiration or pneumoniae. New method to avoid this complication is desired.

Patients and methods: 702 patients who received thoracoscopic esophagectomy in our institute from March 1995 to October 2017 were enrolled and studied retrospectively. Operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment or definitive chemoradiotherapy before surgery. Overall survival rate of the patients with thoracoscopic approach and with thoracotomy until 2001 was analyzed. Long term outcome of the patients with thoracoscopic esophagectomy was compared to the result from comprehensive registry of esophageal cancer in Japan. Short term results of the perioperative parameters were analyzed between left lateral decubitus position and prone position.We had introduced intraoperative nerve monitoring system for prone esophagectomy from 2014.

Results: There was no significant differences of the survival rate between thoracoscopic group and thoracotomy group based on pathological stage. 5 year survival without neoadjuvant treatment was 88.9% (pStageI), 71.5%(pStageIIA), 68.1%(pStageIIB), 40.9%(pStageIII), respectively.5 year survival rate of cStageII and III with neoadjuvant chemotherapy was 65.7% and 5 year survival rate of the salvage esophagectomy after failure of definitive chemoradiotherapy was 31.4%. Every outcomes are as good as any reported results in esophagectomy. In the comparison of the lateral position with the prone position, total blood loss was significantly lower in prone position. Inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommended as a minimally invasive procedure for thoracoscopic esophagectomy. Transient recurrent laryngeal nerve palsy was observed 30% of patients.

Conclusion: Thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. Nerve monitoring is useful for detecting recurrent nerve and avoiding nerve injury.



M. Abdeldayem 1, J. Waterman1, J. Rogers2, D. Brown3, P.N. Haray4 1Colorectal Surgery, Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom; 2Obstetrics and Gynaecology, Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom; 3Digimed®, ESSEX, United Kingdom; 4Colorectal Surgery, University of South Wales, WALES, United Kingdom

Background: Laparoscopic Total Mesorectal Excision (TME), in a wide female pelvis is usually technically easier than in a narrow male pelvis. However, this is not always the case, as the uterus and adnexae may obscure the views and hinder safe dissection, especially in obese patients. Techniques such as graspers through additional ports or suspension with sutures through the broad ligament may potentially cause injury or need additional ports/assistants.

Aim: We present a novel technique using a self-retaining gynaecological uterine manipulator to improve access during deep pelvic laparoscopic surgery in female patients.

Technical tip: The operation is commenced in the standard manner for a laparoscopic rectal excision. Once pelvic dissection is commenced, whenever it is felt that uterine retraction would be advantageous (depending on the level of the rectal tumour, size of the uterus and ovaries, obesity etc.) a self-retaining uterine manipulator (as shown in the video) is used. The tip of this disposable device is introduced into the uterus after dilatation of the uterine cervix. Once the balloon at the tip has been inflated, the instrument is secure and hence there is no need for active manipulation by an assistant. The shaft can be rotated to allow anteversion/retroversion of the uterus to varying degrees as required to aid dissection. As the video depicts clearly, it acts as a self-retaining retractor for the uterus and is removed at the end of the operation. Though the procedure is being demonstrated by a gynaecologist in the video, the instrument is quite easy to insert and some of our colorectal team have been trained as well.

Conclusion: The self-retaining uterine manipulator is an efficient tool for uterine retraction in laparoscopic rectal surgery and we have been using it routinely in TME in females for the past 8 years, with no complications. This was previously published as a technical tip in the Journal of minimal access surgerybut has never been submitted for peer review as a video.

V006—UPPER GI—Benign Esophageal disorders


H. Cardoso-Louro, S. Graça, L. Lencastre, A. Fonte-Boa, J. Vilaça General Surgery, Hospital da Luz Arrábida, PORTO, Portugal

Aims: Since the early 2000 s new cervical endoscopic approaches have been described. Zenker’s diverticulum (ZD) is a false diverticulum at the level of the upper oesophageal sphincter resulting from a motor dysfunction between the lower pharyngeal constrictor muscle and the cricopharyngeal muscle (Killian triangle). The surgical treatment consists of cricopharyngeal myotomy with or without diverticulectomy.

The authors present a video of two clinical cases treated by trans-axillary endoscopic approach.

Methods: A 74 years-old male and a 73-year-old male presented with intermittent dysphagia and frequent reflux (class II of Lahey). One had a history of recurrent respiratory infections. The disease was characterized by oesophagogastroscopy (EGD) and oesophagogram.

Trans-axillary approach with areolar port. Step-by-step as follows: (i) dissection anteriorly to the pectoralis major muscle (ii) isolation of the anterior border of sternocleidomastoid muscle (iii) omohyoid muscle’s isolation (iv) identification of the thyroid’s upper pole (v) ZD isolation (vi) myotomy of the cricopharyngeal muscle (vii) ZD’s resection with stapler and its withdrawn with sac.

Results: Both cases progressed without complications. Complete local recovery was verified in both cases one month after the procedure.

Conclusion: This technique seems feasible and reproducible, allowing ZD diverticulectomy with a better cosmetic result and perhaps lower surgical site infections (SSI). In the authors’ knowledge, this approach to DZ has never been published.

V007—UPPER GI—Esophageal cancer


K. Otsuka, M. Murakami, S. Goto, S. Akira, K. Fujimasa, M. Kohmoto, R. Kato, T. Ariyoshi, T. Yamashita, T. Aoki Gastroenterological and General Surgery, Showa University, TOKYO, Japan

Introduction: Recurrent laryngeal nerve paralysis(RLNP) is considered a major postoperative complication of esophageal surgery. Although it depends on the extent of lymph node dissection performed, the incidence of RLNP after esophagectomy is reported from 8.3% to 40.9% By avoiding direct nerve injury, unreasonable traction force, thermal damage and other factors associated with RLNP, the incidence of RLNP should be minimized. We reviewed dissection techniques to limit the occurrence of RLNP, with specific attention to the anatomical layer around the recurrent laryngeal nerve. This technique is no touch, no traction and results in no injury to the recurrent laryngeal nerve, maintained in its anatomical position.

Methods: From September 2016 to December 2018, minimally invasive esophagectomy was performed in the left lateral decubitus position in 83 patients with esophageal cancer. The No-Touch Dissection technique for lymphadenectomy around the recurrent laryngeal nerve was performed and all patients evaluated for recurrent laryngeal nerve paralysis.

Results: Minimally invasive esophagectomy was completed in all patients without conversion to thoracotomy. Although an extended lymphadenectomy was performed in all patients, there were no grade II or higher complications (Clavien-Dindo classification) and no incidence of recurrent laryngeal nerve paralysis.

Conclusion: This No-Touch Dissection technique may reduce the incidence of recurrent laryngeal nerve paralysisafter minimally invasive esophagectomy with radical lymph node dissection.




S. Sanchez-Cordero 1, R. Vilallonga2, R. Roriz2, M. Kraft2, E. Caubet2, O. Gonzalez2, Y. Curbelo2, J.M. Fort2, M. Armengol2 1General Surgery Department, Consorci Sanitari de l’Anoia, IGUALADA, Spain; 2Endocrine-Metabolic and Bariatric Surgery, Hospital Universitari Vall d’Hebron, BARCELONA, Spain

Background: Gastric leak occurs in 1–6% of patients who undergo Roux-en Y gastric bypass (RYGB) for morbid obesity. The pathophysiology may be related to gastric ischemia, fistula, or ulcer.Gastric leak is a severe complication of gastric bypass (GBP) that is associated with significant morbidity and mortality. Fistula may have several clinical impacts, depending on patient-related factors, fistula characteristics, onset time, and therapy proposal. Abdominal drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results.

Methods: We present a video of a clinical case of 44-year-old lady with body mass index of 45 Kg/m2 who underwent Roux-en-Y gastric bypass and 48 h later presentedtaquicardia and right cuadrantum pain. The CTscan inform a apical leak at the gastric pouch level. The video shows the relevant aspects of a revisional surgery and the key points to drain the fistula and close de defect laparoscopically.

Results: After 6 monts, the patient achieved succesful results, defined as a stabel clinical situation with image evidence of gastric fistula remision.

Conclusions: Gastric bypass (GBP) is one of the most efficient bariatric interventions in morbidly obese patients. The most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. Without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after GBP.



L. Castagneto Gissey, G. Casella Department of Surgical Sciences, Sapienza University of Rome, ROME, Italy

Laparoscopic sleeve gastrectomy (LSG) has become the most commonly performed operation worldwide as a primary bariatric/metabolic procedure. However, conversion to other surgical procedures such as Roux-en-Y gastric bypass (RYGB) or one anastomosis gastric bypass (OAGB) have been described as treatment options for inadequate weight loss after LSG and unresolved co-morbidities or complications such as leak, stricture, and severe gastroesophageal reflux disease (GERD). We present two clinical cases of weight regain and severe GERD and dysphagia, which account for the main indications to reversal of LSG to either OAGB or RYGB.



M.J. García-Oria, A. Sánchez, E. Jimenez, P. Pla, C. León-Gámez, L. Román, X. Remirez, X. Rial, A. Equisoain, D. Gonzalez, V. Polaino, M. Suarez, E. Iglesias, J.A. Rivera, Cirugía General y del Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, MADRID, Spain

Aims: We show in the video the surgical technique that we perform by laparoscopic aproach, in order to construct a Roux-en-Y polipropilene banded gastric bypass LRYGB-B.

Methods: We are performing this procedures within a prospective randomized trial that is design to compare the long term results of LRYGB-B versus the standard laparoscopic Roux-en-Y gastric bypass.The video shows our technique in a case of a 46 years old female with a BMI of 46 Kg/m2. First we create a vertical gastric pouch of about 25–30 ml, and a polypropylene mesh (10x65 mm) is placed 20–30 mm proximal to the anastomosis around the gastric pouch, with the help of a laparoscopic band retractor. After that a 150 cm Roux-en-Y limb is constructed in an antegastric antecolic fashion, been the lenght of the biliary limb 100 cm. A 25 mm gastroyeyunal anastomosis is performed with a linear stapler, and the enterotomy and gastrostomy are closed with a 3/0 barbed running sutures. Jejunojejunostomy anastomosis is constructed in similar fashion, but with a lenght of 30–45 mm. The Petersen space and the mesenteric defect are closed with polipropilene 0/0 sutures.

Results: 31 patients has been operated following this technique, and there has been no complications related to the polipropilene band. (The ramdomized prospective trial is still ongoing).

Conclusions:The video shows a reproductible easy way to perform a LRYGB-B using a polipropilene mesh.



M. Ooms, J. Colpaert, G. Uijtterhaegen, S. Sagaama, B. Dillemans Department of Surgery, AZ Sint-Jan, BRUGGE, Belgium

Introduction: A 23-year old female patient presented at our clinic two years after initial Roux-en-Y gastric bypass. She had had a preoperative BMI of 31,5 and had a significant weight loss which resulted in a BMI of 21,4 at two years postoperatively. She currently suffered from severe dumping with glycaemia levels dropping to 30 mg/dL. Pharmacological treatment with metformine, sandostatine and acarbose did not yield any results. On top of these problems she felt less restriction, could eat large portions and had gained 9 kg in the last three months.

Objective: The usual approach for severe dumping-related hypoglycemia would be to undo the gastric bypass. This patient however was extremely anxious to regain weight, so we sought other options. We assumed that by adding more restriction and slowing down the emptying of the gastric pouch we could alleviate some—if not all—of the dumping related symptoms and prevent further weight regain.

Methods: In this video we present the banding of a gastric pouch for severe dumping after Roux-en-Y gastric bypass.

Results: Although unconventional, the banding of the pouch yielded excellent results. The slower pouch emptying and reduced portions resulted in a near complete remission of all symptoms. As an additional benefit we found a slight weight loss of four kilograms six weeks postoperatively.

Conclusion: The usual treatment of severe dumping-related hypoglycemia would be an undo of the gastric bypass. In this case however the patient was extremely anxious to regain weight, being very pleased with the results her gastric bypass had yielded. In agreement with both the patient and treating endocrinologist we attempted a different approach. The slower pouch emptying and increased restriction offered another way to alleviate the dumping and deep hypoglycemia while concomitantly resulting in weight maintenance.



D.J. Garcilazo Arismendi, E. Cuello Guzman, L. Lammers, S.T. Makkai-Poppa, M. Goergen, J.S. Azagra Soria Department of General Surgery & Urology, Mini-Invasive and Oncologic Surgery, Centre Hospitalier de Luxembourg, LUXEMBOURG

Background: Sleeve Gastrectomy (SG) has earned acceptance as one stage Surgical treatment of Obesity and nowadays is the most performed Bariatric procedure worldwide. Currently reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.

Aims: We present a High Definition video to describe our technique of ‘3-Ports Sleeve Gastrectomy’ which mimics all the fundamentals aspects of the conventional laparoscopic Sleeve Gastrectomy approach (5 Trocars) while incorporating some innovative technical features to reduce the quantity of ports (3 trocars); nonetheless maintaining triangulation and without the use of special equipment, a long learning curve or detrimental in exposure or ergonomics.

Methods: We present a high definition video describing our technique of ‘Reduced Ports Sleeve Gastrectomy’ inthe case of a 26-years old female with an initial Body Mass Index (BMI) of 79,1 Kg/m2 withhistory of diabetes, arterial hypertension and obstructive sleep apnea syndrome; within a two-stage Gastric Bypass project for Obesity treatment

Results: Postoperative outcomes were uneventful. The patient shows a significant weight loss at 1 year follow-up with a change of BMI of 39,5 kg/m2 (1-year BMI 39,6 Kg/m2), a percent of total weight loss (%TWL) of 50.5%. (Initial weight: 200 kg—1 year weight: 99 kg) and a percent of excess weight loss (%EWL) of 73,83%; with complete resolution of the comorbidities.

Conclusions:Our technique can be a useful, safe and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results and team dynamics and represent an alternative to conventional laparoscopic and single port surgery.



G. David, G. Cesana, F. Ciccarese, M. Uccelli, R. Giorgi, R. Villa, S. de Carli, G. Poli, A. Zanoni, A. Oldani, S. Olmi General Surgery, Policlinico San Marco, ZINGONIA, BG, Italy

Aim: The aim of this video is to present a novel surgical technique to avoid stent migration after endoscopic placement in patients with leakage subsequent to laparoscopic sleeve gastrectomy (LSG).

Methods: This video shows the case of a patient (BMI 46,6 kg/m2) who developed an upper gastric leakage 2 days after LSG. A CT scan showed a small leakage at the EG junction complicated by intra-abdominal abscess. A CT guided percutaneous drainage of the abscess was performed. A stent placement was attempted endoscopically three times and failed for migration. We decided to place laparoscopically a non adjustable gastric ring (NAGR) around the stomach, in order to avoid stent migration.First of all the stent is replaced endoscopically in order to cover the fistula tract. The patient is placed in a half sitting position and the pneumoperitoneum was obtained using a Veress needle in left subcostal space. A 4 port technique is used as in standard laparoscopic sleeve gastrectomy.The procedure starts with the mobilization of adhesions, the fistula is identified in the upper part of the tubule.The gastric tubule is isolated and the lesser omentum is opened. The blunt needle at the tip of the ring is passed retrogastrically, a tourniquet can be useful is the positioning turn out to be difficult. The NAGR is then closed over the gastric tubule containing the stent. A drain is finally placed.

Results: The stent was removed after 4 weeks. A gastrointestinal CT scan with oral contrast showed a complete resolution of leakage. After 6 months the patient was in a good condition with BMI 29,4 kg/m2. The stent was endoscopically removed after 4 weeks. A gastrointestinal CT scan with oral contrast showed a complete resolution of the leakage. After 6 months the patient was in a good condition with BMI 29,4 kg/m2.

Conclusions: This new technique is feasible and effective, as shown in this video; however the NAGR can lead to complications, so a strict follow up is needed and if any complication appears, should be considered to remove laparoscopically the ring.



J. Colpaert, M. Ooms, K. Jacobs, I. van Campenhout, L. Maes, B. Dillemans Department of Surgery, AZ Sint-Jan, BRUGGE, Belgium

Introduction: In this case, we will discuss the case of a 72 year old male patient who underwent a laparoscopic cruraplasty and gastric plication resulting in a weight loss of 12 kg. Other medical history reported insulin-dependent diabetes, reflux esophagitis and sleeping apnea with CPAP. Two years after gastric plication the patient presented with passage problems, gastro-esophageal reflux and epigastric pain. To this end a swallow test was performed revealing a large fundus with a restricted passage of contrast. Due to the persistent complaints and the abnormal findings on barium swallow a surgical re-intervention was needed.

Objectives: Despite the current BMI of 27 and the age of the patient, conversion from a gastric plication to a Roux-en-Y gastric bypass was performed. Several other surgical options were considered, including an undo of the gastric plication or a dilatation with a resizing of the fundus.

Methods: In the video we describe the laparoscopic approach for a conversion of a gastric plication to a Roux-en-Y gastric bypass.

Results: At 6 months follow-up the patient showed a weight loss of 8 kg and the resolution of his earlier symptoms. The patient had a normal oral intake without any gastro-esophageal reflux or epigastric pain.

Conclusion: After a gastric plication, partial loosening of the sutures and stenosis are both well-known complications. As presented in the video, it is apparent that a laparoscopic undoing of gastric plication is not as straightforward as it seems. Firm adhesions between folds can compromise the procedure and inhibit a complete separation of the tissues. We believe that in these cases the best surgical approach is to convert to a Roux-en-Y gastric bypass.



V. Palumbo 1, E. Schembari1, M. Teodoro1, O. Coco1, G. la Greca1, S. Latteri1, A. Pesce2 1Chirurgia Generale, Cannizzaro, CATANIA, Italy; 2Department of General Surgery, Policlinico Hospital, University of Catania, CATANIA, Italy

Laparoscopic sleeve gastrectomy (LSG) is a relatively new surgical approach in the weight loss surgeon’s armamentarium. In literature there is a consensus about the importance of mobilizing completely the gastric fundus before transection. The ReSG (revised sleeve gastrectomy- resleeve) may be a valid option for failure of primary LSG. We focused the attention on the consequences that can have an incomplete resection of gastric fundus during an operation of sleeve gastrectomy and how they can be solved by the repetition of this procedure.

A sleeve gastrectomy was performed in an obese 34-year-old woman (BMI = 40). Three days after the operation, an upper GI x-ray with gastrografin did not show any abnormalities. Three months after the surgical procedure, the woman referred frequent episodes of vomiting and a significant weight loss (42 kilos). An upper GI x-ray with gastrografin demonstrated the presence of multiple communicating cavities of the gastric fundus. The esophagogastroduodenoscopy (EGD) showed that the gastric tube close to the esophagogastric junction was separated from a recess (2–3 cm in diameter) by an incomplete septum. A severe hypokalemia and consequent ECG abnormalities were treated with intravenous infusion of potassium. Then, we performed a laparoscopic operation. The gastric tube was completely released along the suture line of the previous operation and, especially, the posterior surface of the upper part until the left crus of diaphragm became evident. Under the guide of the bougie, the recess was removed.

Results: The clinical course was regular, and the patient was discharged on third post-operative day after an upper GI x-ray with gastrografin which demonstrated the absence of leakage and a normal gastric tube. After 1 year, the patient was very satisfied with the operation.

Conclusions: The complete mobilization of the gastric fundus allows to see clearly which part should be resected to obtain an adequate gastric tube and facilitate a correct placement of the stapler. In our experience, in patients with a residual fundus, an upper GI x-ray with gastrografin and an EGD are needed to exclude the presence of stenosis. Then, a resleeve gastrectomy is an efficient and safe procedure to treat this post-LSG complication.



A. Peri1, M.S. Milani 2, F.C. Bruno1, N. Mineo1, S. Malabarba1, S. Carando1, A. Pietrabissa1 1General Surgery 2, IRCCS Policlinico San Matteo, PAVIA, Italy; 2General Surgery, IRCCS Policlinico San Matteo, PAVIA, Italy

Weight regain is one of the main problems in bariatric surgery. We have many surgical option but when we evaluate patients with long follow up and BMI of superobese patient before the first surgery, the weight recidivism can arrive up to 50–70% at 5 years.In most cases the first surgery is a restrictive procedure, and in many cases sleeve gastrectomy.Here we present a case of weight regain after laparotomic Super-Magenstrasse (that we consider like a sleeve gastrectomy except for remnant removal) with a big incisional hernia. After a complete multidisciplinary re-evaluation we decided to perform an OAGB (one anastomosis gastric bypass) but in this case we decided to create a functional exclusion to the duodenal transit by positioning a minimizer ring. This solution is effective in food diversion and guarantee gastric and duodenal endoscopic exploration in case of need. We think that this technique can represent an option to take in account for selected cases. At the end of bariatric procedure we perform a laparoscopic repair of incisional hernia with mesh in the hope to avoid future surgery and post operative small intestine herniation.



J. Trébol 1, J.A. Gazo-Martínez2, P. Maté-Maté2, J.E. Quiñones-Sampedro1 1General and Digestive Tract Department, Complejo Asistencial Universitario de Salamanca, SALAMANCA, Spain; 2General and Digestive Tract Department, Hospital Universitario La Paz, MADRID, Spain

Aims: Erosion of Laparoscopic Adjustable Gastric Banding (LAGB) is uncommon and its clinical course is usually benign. We present and oligo-asymptomatic lesser curvature erosion diagnosed under scheduled LAGB removal repaired with laparoscopic suturing.

Methods: A 65 year-old female (BMI 35.38) with arterial hypertension and postoperative hypothyroidism was scheduled for a LAGB removal due to refractory vomiting. No information about LAGB type or surgical technique was available. A four port laparoscopic approach was performed sectioning the perigastric band with scissors over anterior gastric serosa. A longitudinal defect on the lesser curvature, in the place previously occupied by LAGB, was identified.

Results: A laparoscopic suturing using single stitches with 3/0 poliglactin 910 and 3/0 polidioxanone barbed suture was performed (showed on video). An intraoperative gastroscopy was performed to confirm suture tightness. Oral intake was resumed once normal upper GI series were obtained three days later. The patient was discharged on the sixth postoperative day. LAGB was infected with Enterobacter cloacaeand Candida glabrata </i >. Normal endoscopy was obtained two months later.

Patient rejected additional bariatric procedures and in fact she has gained 10 kg two years later (BMI 39.14).

Conclusions: LAGB gastric erosion is uncommon (1.46–3%). Intraoperative (such as perigastric approach) and patient related factors (smoking, alcohol…) have been described as risk factors.

The most frequent clinical presentation is weight loss failure; band and port issues (such as infection) are also frequent. Erosion is infrequent to present as an acute event (< 5%: peritonitis, abscess…) or asymptomatically (< 1%). Diagnosis is mostly performed under upper endoscopy.

The most common therapeutic technique is removal of the band (by endoscopy or surgery), repair of the stomach, if needed, and band replacement (at least three months later). Some authors have performed immediate replacement but the incidence of recurrent erosion seems to be higher. Other options are LAGB removal alone or conversion to different bariatric procedure. For endoscopic removal, it has been advised to wait until the band buckle is in the stomach and is sometimes very difficult. Replacement of the band is not associated with weight regain.



H. Segura-Marin 1, B. Leal-Gonzalez2, G. Arredondo-Saldaña1, J.A. Diaz-Elizondo1 1General Surgery, Escuela de medicina del Tecnologico de Monterrey, MONTERREY, Mexico; 2Baritatric Surgery, Escuela de medicina del Tecnologico de Monterrey, MONTERREY, Mexico

Female patient of 45 years, Diabetic of 12 years of evolution, surgical history of 3 C-sections, last performed in 2001 and a conventional appendectomy in 2005. She reports 5 years of evolution presenting moderate intensity heartburn that was exacerbated during the night as well as submit occasional rejurgutation. The intensity of the symptoms is attenuated by maintaining a diet without irritants and improving feeding times. Denies hematochezia, unintentional reduction of weight, dysphagia or early satiety. The patient has suffered from obesity since childhood, after pregnancy she had progressive weight gain and difficulty in controlling blood sugar, so she is scheduled a gastric bypass Roux-en-Y . Preoperative endoscopy was performed, evidencing submucosal tumor in the gastroesophageal junction at 37 of the dentary arch, approximately 3 cm in diameter. An endoscopic ultrasound was performed, demonstrating subepithelial lesion of the gastroesophageal junction, hypoechoic, with well-defined borders, pseudobilobulated, 2.4 cm x1.3 cm, and dependent on the external muscular layer. A fine needle aspiration is performed in which spindle cells are identified, Leiomyoma is likely diagnosed. It is programmed for laparoscopic resection of submucosal gastric tumor, gastric bypass and laparoscopic cholecystectomy. A Tumor at the level of the gastro esophageal junction of approximately 2.5 cm is identified in the surgery, which can be resected by laparoscopy without complications. The patient is discharged after 2 days of postoperative stay. The final histopathological result: leiomyoma of 3.3 cm with free edges. CD4 (−) GOG1(−) Caldesmon (+)s100 (+).



M.Y. Fanous Surgery, Aspirus Iron River Hospital, IRON RIVER, United States of America

Introduction: Minimally invasive repair of adult Morgagni hernia is gaining popularity. Given its rarity, there is no consensus regarding the dissection/excision of the sac or the use of mesh. Morbid obesity adds to the operative complexity and to the postoperative challenges.

Aim: To evaluate the safety and efficacy of laparoscopic repair of giant Morgagni hernia- with sac dissection and mesh augmentation- in morbidly obese patient.

Methods: This patient is a 60 year old female with BMI of 45 who has past medical history of diabetes, asthma, anxiety and gastroesophageal reflux disease. Patient had intermittent chest pain for 3 months. Extensive workup, including CT of the chest, revealed giant right sided Morgagni hernia.

Result: Patient underwent elective laparoscopic repair. Four ports were placed in the upper abdomen. She was placed in Reverse Trendelenberg position. The transverse colon and its omentum were reduced. The liver attachments to the diaphragm were divided. The diaphragmatic defect measured 6 x4 cm. The sac was dissected and excised. This was achieved by scoring the inferior edge of the defect. The proper plane was easily identified laterally. A raytec gauze was placed to create space and to allow for diffusion of carbon dioxide. The sac was dissected of the mediastinal structures and excised. The defect was closed using interrupted permanent sutures tied extracorporeally with modified Duncan Loop. The repair was reinforced with coated mesh. Patient tolerated the procedure well. Her length of stay was two days. There were no postoperative complications. Patient was seen in clinic 5 months postoperatively as she reported abdominal pain with heavy lifting. CT showed no evidence of recurrence of Morgagni Hernia.

Conclusion: Laparoscopic repair of adult giant Morgagni hernia- with complete dissection of the sac and mesh augmentation- in morbidly obese patient is safe and effective. Longer term follow is needed to evaluate the durability of this repair.



R. Vilallonga 1, S. Sanchez-Cordero2, P. Alberti3, R. Roriz1, M. Kraft1, E. Caubet1, O. Gonzalez1, Y. Curbelo1, J.M. Fort1, M. Armengol1 1Endocrine-Metabolic and Bariatric Surgery, Hospital Universitari Vall d’Hebron, BARCELONA, Spain; 2General Surgery Department, Consorci Sanitari de l’Anoia, IGUALADA, Spain; 3General surgery department, Hospital Universitari Vall d’Hebron, BARCELONA, Spain

Background: Fifty percent of patients who have undergone gastric bypass, posterior reversal and sleeve gastrectomy and finally complete hiatoplasty presents symptomatic gastroesophageal reflux disease. Surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. Here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous conversion of sleeve gastrectomy to gastric bypass and hiatal hernia repair.

Methods: We present the surgical techhnique performed to a patient with initial gastric bypass who underwent sleeve gasterctomy for hipoglycemias and hiatoplastia for severe GERD. Persistent GERD requested to undergo ligamentum teres cardiopexy. In this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last 3–5 cm of esophagus in the abdomen. The distal ligamentum teres is fixed with one stitch to the apex of the angle of His, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. The remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. The procedure concludes with diaphragmatic crus closure.

Results: After 3 months, the patient achieved successful results, defined as resolution of GERD, no protonpump inhibitor (PPI) use, and manometry measurement over 12 mmHg after surgery.

Conclusions: Ligamentum teres cardiopexy combined with closure of the gastric crus is a late alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia.



B.A. Smeu General surgery, Ponderas Academic Hospital, BUCHAREST, Romania

Introduction: As metabolic surgery techniques evolve during the years, we have to face more and more patients with complications ands uboptimal results after the older/initial procedures. Vertical banded gastroplasty(VBG) is one of those procedures that gain momentum during the initial experience in bariatric surgery, but has proven to have dissapointing results and a lot of complications, nowadays surgeons having to deal with difficult revisional operations.

Aim in this video: we want to present from our experience the difficulties encountered during the revisional surgery, Rouxen Y Gastric Bypass (RYGBP)afterVBG, and the tips and tricks that will make this a safer and easier procedure.

Material and Methods: Between 2011–2018 we had 39 revisional surgeries after open VBG, all of them by laparoscopic approach, most of them redos to LRYGBP (34/39–87.1%)and the rest revisions to sleeve gastrectomy (5/39—12.9%). Most of the indications for revisional surgery after VBG were for complications (stenosis, dysphagia, band migration, gastro-gastric fistula) and suboptimal result with weight regain. We present our technique for LRYGBP after VBG emphasizing the possible pitfalls and tips and tricks needed for a safer and easier procedure.

Results and Discussions: All patients were operated in ourCenter of Excelencefor Bariatric and Metabolic Surgery (COE) and went well postoperatively, without any major complications (no leaks, no mortality) and only minor and temporary complications: temporary dysphagia in 2 patients (4 and 7 PO days, remitted afterconservatory treatment), and 2gastro-jejunalanastomosis bleeding (endoscopic treatment). The mean operative time was 165 min (115 to 365 min) and mean hospital stay 5,4 days (3 to 12 days).

Conclusions: Although the revision surgery after VBG is technique demanding, we consider it to be a safe procedure in the hands of experienced metabolic surgeons, with good postoperative results.



J. Colpaert, M. Ooms, G. Uijtterhaegen, B. Dillemans Department of Surgery, AZ Sint-Jan, BRUGGE, Belgium

Introduction: We present a 53 year old male patient with documented ethylic liver cirrhosis and portal hypertension. He weighed 124,2 kg for 170 cm, resulting in a BMI of 43. In the further preoperative workup we find fundal varicosis without esophageal varices on gastroscopy. This suggests mild to moderate portal hypertension and thus an increased surgical risk.

Objective: After thorough preoperative assessment and a review of the literature multiple treatment options were considered. The procedure of choice ended up being a laparoscopic adjustable gastric banding, with the objective to achieve optimal weight loss with the lowest risk for complications.

Methods: In this video we present the placement of an adjustable gastric banding in a patient with a cirrhotic liver and portal hypertension and the possible pitfalls.

Results: Postoperatively there were no complications and patient had a satisfying weight loss both 6 months and 1 year postoperatively. In a short review of the literature we’ve found that bariatric surgery is feasible in patients with portal hypertension as long as the patient is not decompensated or has bleeding varices.

Conclusion: Cirrhosis and portal hypertension are no absolute contraindication for banding, sleeve or RNY gastric bypass as long as the patient is not decompensated or has bleeding varices. The type of surgery is dependent on patient and surgeon-related factors. The aim should be to achieve optimal weight loss with the lowest possible surgical risk in this type of patients.



M. Ooms, J. Colpaert, E. Melsens, L. Ruyssinck, L. Maes, B. Dillemans Department of Surgery, AZ Sint-Jan, BRUGGE, Belgium

Introduction: In this case, we will discuss on a 54 year old female patient who had undergone a laparoscopic Nissen fundoplication 5 years ago due to GERD grade B. Because of morbid obesity a N-sleeve gastrectomy was performed 1 year ago resulting in a weight loss of 12 kg. At presentation she had regained all the lost weight, resulting in a BMI of 42,8. The patient history also reported insulin-dependent diabetes and obstructive sleep apnea with CPAP. Gastroscopy was performed showing a large residual fundus but no esophagitis. On the subsequent upper GI series a relatively wide sleeve with an intact Nissen-collar was detected.

Objectives: A laparoscopic conversion to a Roux-en-Y gastric bypass was performed. Other potential surgical treatment options are a SADI procedure or a sleeve gastrectomy with transit bipartition (Santoro procedure).

Methods: In the video we describe the laparoscopic approach for a conversion of a N-sleeve to a Roux-en-Y gastric bypass.

Results: At 4 month follow-up the patient presented with a weight loss of 12 kg. The patient had good restriction on oral intake and did not have any reflux-related symptoms or complaints.

Conclusion: Conversion from a N-sleeve to a Roux-en-Y gastric bypass is a challenging procedure. The largest pitfall during the creation of the gastric pouch is to staple a double fold of the Nissen fundoplication. We believe that in these rare cases of weight regain after N-sleeve, the best surgical approach is to convert to a Roux-en-Y gastric bypass.



M. Ooms, J. Colpaert, G. Uijtterhaegen, K. Jacobs, B. Dillemans Department of Surgery, AZ Sint-Jan, BRUGGE, Belgium

Introduction: A 44-year old female patient with extensive bariatric history presented at our hospital. She had had a gastric balloon in 2005 and a laparoscopic vertical banded gastroplasty (VBG) in 2006. Four years later, in 2010, a laparoscopic conversion to Roux-en-Y gastric bypass was performed because of weight regain. She now presents with satisfactory and stable weight loss over the last few years. She was recently diagnosed with a BRCA-1 mutation for which she underwent a bilateral ovarectomy and mastectomy. The patient’s brother was also diagnosed with this mutation and died of pancreatic cancer at the age of 39. Genetic counseling advised a two-yearly follow-up because of an increased risk up to 10% of developing pancreatic cancer. Control gastroscopy showed a normal esophagus and gastric pouch. Control CT scan revealed hypertrophic stomach creases in the excluded stomach. These results prompted a laparoscopy-assisted gastroscopy of the excluded stomach which uncovered hypertrophic stomach glands and intestinal metaplasia on biopsy.

Methods: In this video we demonstrate the laparoscopic approach for complex revisional bariatric surgery. Conversion from RNY gastric bypass to a sleeve gastrectomy in a patient who already underwent a VBG. The focus of the video is on a manual gastro-gastrostomy with partial gastrectomy of the fundus and part of the stomach where the old VBG-band was placed.

Results: After 1,5 months follow-up the patient had no complaints and a stable weight. Upper GI series shows a normal passage of contrast through the sleeve gastrectomy.

Conclusion: Endoscopic surveillance of the remnant stomach and echo-endoscopy of the pancreas is no longer possible after RNY gastric bypass. In cases where the need for such a surveillance arises after a RNY bypass a patient-tailored approach is necessary. In our patient a laparoscopic conversion from a RNY gastric bypass to a sleeve gastrectomy was performed. This approach keeps the patient’s wish for weight loss intact while enabling further surveillance through natural-orifice endoscopy.



S. Inamine 1, H. Nakazato2, T. Takaesu1, A. Gabe1, J. Oshiro1 1Surgery, Ohama Daiichi Hospital, NAHA CTY OKINAWA PREFECTURE, Japan; 2Surgery, Okinawa Red Cross Hospital, NAHA, Japan

A 47-year-old morbidly obese Japanese woman with a body mass index of 41 kg/m2 suddenly complained of swallowing difficulty 4 months after laparoscopic Roux en Y gastric bypass surgery with retro-colic Roux limb route. An internal hernia of the defect of the transverse mesocolon was suspected by computed tomography, and emergency intervention was performed. The surgery revealed no internal hernia. However, strong inflammation and adhesion were observed between the transverse mesocolon and the retrocolicRoux limb. In addition, the Roux limb on the oral side of the adhesion site was dilated and bent.The adhesion between the transverse mesocolon and the flexed Roux limb was dissected, linearized and re-fixedby suturing to the transverse mesocolon. However, since the difficulty of oral intake persisted re-do surgery was performed again. After resecting the Roux limb involved in the severe inflammation, a ‘new’ Roux limb was lifted to the cephalad via the ante-colic route. Finally, the gastric pouch and Roux limb were re-anastomosed with 3-0 absorbable sutures in an interrupted full thickness single layer manner. In the present case, we experienced difficulty with both adhesiolysis and determining the accurate target line to resect at the ‘old’ gastrojejunostomy. However, blocking the blood flow of the ‘old’ Roux limb facilitated the accurate recognition of the target line.



M. Pérez Reyes1, A. Rodríguez Cañete 1, F.J. Moreno Ruiz1, C. Montiel Casado1, J.L. Fernández Aguilar1, P. Fernández Galeano1, I. Mirón Fernández1, J. Santoyo Santoyo2 1Esofagogástrica, Cirugía General y Ap Digestivo, Hospital Regional Universitario de Málaga, MALAGA, Spain; 2Hepatobiliopancreática, Hospital Regional Universitario de Málaga, MALAGA, Spain

Introduction: Marginal ulcer is one a serious complications after a bariatric gastric bypass. Tobacco, non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori (HP) infection are known risk factors.

Methods: We present a 29-year-old women operated 3 years before of bariatric surgery with a gastrojejunal (GY) bypass technique due to intraoperative dehiscence of the staple line after attempting a vertical gastrectomy (sleeve). She has persistent vomiting and epigastralgia from 3 months after the intervention, affecting his quality of life.

Upper gastrointestinal endoscopy (UGE) was performed, describing an ulcer in the GY anastomosis. She started HP eradication treatment, treatment with proton pump inhibitors (PPIs), tobacco and NSAIDs were discontinued, but she had slight improvement. After 6 months the UGE was made again, which show peptic esophagitis and 2 marginal ulcers. The plasma gastrin level was normal.

Due to the persistence of symptoms despite conservative treatment, we decided reoperation by laparoscopy. We found herniated bowel in Petersen space, which were reduced and the space was closed. We proceeded to truncal vagotomy. The GY anastomosis was resected (fig. 1) and performed again. Finally, we perform antrectomy. The pathological anatomy showed ulceration. She was diacharged home on the 5th postoperative day without any complications.

Results: A marginal ulcer after bariatric surgery appears in the jejunal mucosa of the g-y anastomosis. The symptoms are epigastric pain, nausea and vomiting. Acid, tobacco, NSAIDs and HP infection has an important role in their development < sup > .</sup > The first treatment is medical, discarding out the risk factors, but if it is not effective, it will be surgical, resecting the previous anastomosis. The usefulness of vagotomy is debatable, but the percentage of success increases. In our case, we perform antrectomy to avoid retained antrum syndrome.

The hernia through Petersen space is a cause of intestinal obstruction and abdominal pain as the case presents. Although we believe that the symptoms were mainly caused by the marginal ulcer, the internal hernia was probably a symptomatic cause.

Conclusion: The treatment of a marginal ulcer is medical, eliminating the risk factors, but if it is not effective, the surgery is indicated.



M. López Saiz, J. Riquelme Gaona, G. Rojas de la Serna, A. Morandeira Rivas, B. Muñoz de la Espada, C. Moreno Sanz Digestive Surgery, General Hospital, La Mancha-Centro, ALCAZAR DE SAN JUAN, Spain

Aim: Hiatal hernia is often a pre-existing condition in morbidly obese patients, sometimes misdiagnosed, which can cause an intractable reflux, nausea and abdominal pain. In this video, we present the cases of two patients scheduled for bariatric surgery with a accompanying hiatal hernia.

Material and methods: Patient 1: 49 years old men with a BMI of 38.2 kg/m2, medical history of arterial hypertension, diabetes mellitus type 2, dyslipidemia and obtructive sleep apnea (OSA) and without clinical signs of gastroesophageal reflux. In the preoperative endoscopic study a hiatal hernia is observed.Patient 2: 61-year-old woman with a BMI of 42 kg/m2, history of hypertension, type 2 diabetes mellitus, dyslipidemia, OSA in treatment with nocturnal continuous positive airway pressure, primary hypothyroidism and clinical gastroesophageal reflux. In the preoperative endoscopic examimation a hiatal hernia is detected.

Results: In both patients, a laparoscopic approach with five ports was carried out. The presence of a obvious hiatal hernia was confirmed in both cases. Hernia sac and distal esophagus were disected and the pillars of the hiatus were sutured, before performing the gastric bypass. Patients recovered uneventfully and were discharged on the third postoperative day.

Conclusions: The Roux-en-Y gastric bypass is considered an adequate treatment in obese patients with gastroesophageal reflux disease. Although the bypass solves the reflux problems by itself, it is recommended to repair detected hiatal hernias.



J. Fernando Trebolle 1, M. Valero Sabater1, S. Borlán Ansón1, B. Cros Montalbán1, J. García Egea1, P. Palacios Gasós1, C. Yánez Benítez1, A. Navarro Barles2, R. Ferrer Sotelo1, J. Escartín Valderrama1, A. García García1, J.L. García Calleja1, E. Gonzalvo González1, J.L. Blas Laína1 1General Surgery, Royo Villanova Hospital, ZARAGOZA, Spain; 2General Surgery, Ernest Lluch Hospital, CALATAYUD, Spain

Aim: To present two alternatives of laparoscopic Roux-en-Y gastric bypass as a surgical treatment of morbid obesity.

Method: Two cases of laparoscopic gastric bypass are presented: a 53-year-old woman (BMI 41), and a 40-year-old woman (BMI 43).

Results: Bowel’s measurements and confection of the gastric pouch are identical in both cases. In the first case, intestinal anastomosis is performed in the inframesocolic compartment once small bowel has been divided. In the second case, such union is made next to the gastrojejunal anastomosis with the bowel uncut, making the section once no leakage has been found

Conclusions: Laparoscopic Roux-en-Y gastric bypass is currently considered one of the technique of choice in the surgical treatment of morbid obesity. There are variations and alternatives for its realization. To know them can allow to individualize the technique to each type of patient.



D.J. Garcilazo Arismendi 1, E. Cuello Guzman2, L. Lammers1, B. Pascotto1, M. Goergen3, J.S. Azagra Soria4 1Department of General Surgery & Urology, Mini-Invasive and Oncologic Surgery, Centre Hospitalier de Luxembourg, LUXEMBOURG; 2Centre Hospitalier de Luxembourg, LUXEMBOURG

Background: Sleeve Gastrectomy (SG) has gained momentum as one stage Surgical treatment of Obesity and nowadays is the most performed Bariatric procedure worldwide, nonetheless it’s not exempt of acute or chronic complications difficult to solve. Although SG has shown some degree of efficacy in the treatment of Obese patient with GERD symptoms and some groups do not consider this as a contraindication for this technique, currently the evidence continues to grow towards SG as a promoting factor in the development of De Novo GERD symptoms. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the angular stone in the treatment of morbid obesity and also it’s one of the most effective surgical procedures for GERD.This is the case of a 49-years old male with history of a Sleeve Gastrectomy within a two-stage Gastric Bypass project for Obesity treatment complicated with a invalidant De Novo GERD, 2 months after surgery.

Aims: The purpose is to present our team approach in the treatment of GERD after SG, associating LRYGB with Remnant Gastrectomy in order to increase the efficacy, adding up to the antireflux effects of the LRYGB plus the decrease of Gastrin levels induced by the removal of the gastric remnant.

Methods: We present a high definition video describing our technique of ‘Roux—Y TransmesocolicGastric Bypass with Remnant Gastrectomy for GERD’s treatment’.

Conclusions: Postoperative outcomes were uneventful. The patient shows a complete remission of GERD symptoms immediately after surgery.



C.E. Boru, P. Termine, G. Silecchia Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Sapienza University of Rome, Dept. of Medico-Surgical Sciences & Biotechnologies, LATINA, Italy

Background: Transhiatal sleeve migration, with consecutive gastroesophageal reflux disease (GERD) is a complication that leads to revisional surgery.

Methods: A fifty-five years old, morbid obese female patient with BMI 45 kg/m2, hypertensive with OSAS and hypercholesterolemia, was operated by laparoscopic sleeve gastrectomy in 2010. She reached nadir in 2012 with BMI 28.7, with resolution of her comorbidities. From 2016 she complained from symptomatic GERD not responding to medical treatment,with evidence of transhiatal sleeve migration on radiological contrast study (Gastrografin®), and on the CT scan of the hiatal area.

Results: we present the video of conversion to laparoscopic R-en-Y gastric bypass LRYGB, associated with reinforced cruroplasty with bio-absorbable mesh, with marked improvement of GERD symptoms after reoperation.

Conclusion: laparoscopic conversion from LSG to RYGB is feasible and useful for LSG complications.



J.I. Ortiz de Elguea Lizárraga, R. Alatorre, J. Rojas, E. Flores Villalba, M. Guraieb Trueba, S. Lopez Department of Surgery, Tecnologico De Monterrey, SAN PEDRO GARZA GARCÍA, Mexico

We present a clinical case of a 47 year old female. She had a vertical banded gastroplasty procedure (in another clinic) 9 years ago with an initial weight loss of 30 kg in a period of 2 months.

She was seen at our clinic because she was suffering from dysphagia to solids and general diffuse abdominal pain for the last month.

At physical exam we found a BMI of 39 and nothing else called our attention.

We did an upper GI endoscopy and EGD transit; we concluded that a gastric bypass would offer her the best results.

Therefore, we converted her vertical banded gastroplasty into a gastric bypass laparoscopically. She had an uneventful postoperative period and was discharged home without complications.



P. Fernandez Galeano, M.C. Montiel-Casado, J. Moreno Ruiz, A. Rodriguez Cañete, J.L. Fernandez-Aguilar, Departamento de Cirugía General y Digestiva, Hospital Regional Universitario Malaga, MALAGA, Spain

Aims: SADIS emerged as a modification of biliopancreatic diversion with duodeno-ileal switch (BPDDS) in which after sleeve gastrectomy (SG), the duodenum is anastomosed to an ileal loop in a Billroth-II fashion. SADIS has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients avoiding the high morbidity of biliopancreatic diversion with duodenal switch.

Clinical Case: 50-year-old patient, subjected to bariatric surgery two years ago, including a sleeve gastrectomy (SG). Despite this operation and dietary and hygienic modifications, the patient gained weight in recent months, reaching a BMI of 56 kg/m2 and an overweight of 78 kg. An endoscopy was carried out on her, which provided evidence of a gastric remnant of moderate size with flexible tissue, normal peristalsis, and fast disposal speed. The case was discussed in a joint session, leading to the decision to apply revision surgery. The decision was taken to apply SADIS, a novel technique that had never been used before in Andalucia.

Results: The rate of weight re-gain after the use of classical techniques such as Sleeve Gastrectomy (SG) or the Roux-en-Y gastric bypass (RYBG) is considerable high. Revision surgery due to weight re-gain is necessary in many of these cases. SADIS emerged as a simplified alternative to the use of BPDDS as revision surgery following a GV due to weight re-gain with good short-term results, in terms of both weight control and comorbidity control. Since only one anastomosis needs to be applied, chirurgical time diminishes, as well as the rate of surgery-related complications. Moreover, it could be used, through laparoscopy, for patients who have undergone previous, complex abdominal surgery.

Conclusion: SADIS showed a promising short-term weight loss outcome and comorbidity resolution rate but long-term data are missing and there is currently a high level of technical variability. On the other hand, further studies are required to measure its cost-effectiveness compared to the currently popular bariatric procedures, SG and RYGB.



M.P. Carbonell Aliaga 1, S. Pascual Camarena1, S. Delgado Rivilla2, X. Julian Argudo1, A. Crespí Mir1, A. de la Llave Serralvo1, M. Escales Oliver1, A. Sánchez López1, J.A. Cifuentes Ródenas1 1General Surgery, Hospital Universitari Son Llàtzer, PALMA, Spain; 2General Surgery, Hospital Universitario Mutua de Terrassa, TERRASSA, Spain

Aims: The LPS sleeve gastrectomy is the most common bariatric surgery technique because it has a low surgical complexity and acceptable weight loss results. However, 5-11% of patients present with an insufficient weight loss, weight regnances, reflux or dysphagia. In these cases, it is recommended to perform a second bariatric surgery to combine a component of malabsorption such as gastric bypass or duodenal switch. The video describes the technique of a laparoscopic biliopancreatic diversion with duodenal switch with a previous laparoscopic sleeve. The objective is to describe the safety of the technique and the subsequent success of it.

Methods: A 41-year-old female patient presented morbid obesity with a BMI of 49 after performing a laparoscopic sleeve gastrectomy in 2010. Initially, she presented a percentage of excess weight loss of 62%, reaching a BMI of 33 after two years of follow-up. After this, she suffered a reganancia of all the weight lost despite diet and exercise, presenting a BMI 49. A study was made with TEGD where no complications of the previous surgery or symptoms of gastroesophagical reflux or dysphagia were observed. The LPS duodenal switch is proposed in the obesity unit committee in 2016, without immediate postsurgical complications. The patient presented a favorable postoperative period and was discharged three days postoperatively.

Results: At the present time, the patient has achieved a 98% excess weight loss and has a BMI of 26.5. Presents good oral tolerance with 3 stools a day without urgency. It doesn’t present protein deficioncies. Vitamin deficiencies are orally supplemented.

Conclusion: SThe LPS duodenal switch is a technique that can be performed after a sleeve gastrectomy safely in cases of insufficient weight loss or weight reganancia. The patients presented a greater weight loss after the duodenal switch than after the gastric bypass, observing a lost of excess weight of 74% compared to 64%. The differences being statistically significant.



D.S. Ranev, Y.J. Yatco, M. Roslin Surgery, Lenox Hill Hospital—Northwell Health, NEW YORK, United States of America

Weight regain after gastric bypass is a challenging problem. A number of revisional surgical options have been reported. This is a case of a 48 year-old woman 10 years after LRYGB. Her initial BMI was 67, lowest after surgery—28, at presentation—48. The video shows a robot-assisted laparoscopic conversion of RYGB to loop duodenal switch. The Roux limb is transected and dissected to the gastrojejunostomy. The gastrojejunostomy is resected and the gastric pouch is recreated over a bougie. The gastric blood suply is confirmed with ICG. A gastro-gastrostomy is created to restore gastric continuity and a sleeve gastrectomy is performed. The duodenum is devided and a duodeno-ileostomy is created 300 cm from the ileocecal valve. The remaining Roux limb is resected. The patient recovered uneventfully. Conversion of RYGB to loop duodenal switch requires creation of as little as two anastomoses, in comparison to standard DS, which requires four. It is a safe option for patients with weight regain after LRYGB.



M. Zdrojewski General Surgery Departament, Warmia Masuria University, BARTAG, Poland

18 years old male was admited to the ER due to lower abdominal pain and high fever for 6 days. Physical examination revaled rebound tenderness in every part of the abdominal wall and lab tests showed CRP 450 mg/l, PCT 45 ng/ml and bilirubin level of 6 mg/dl. He was admited to General Surgery department and qualified for the surgery. Laparoscopy showed diffused, purulent peritonitis with lots of adhesions. Further scouting of abdominal cavity revaled infalmated, perforated appendix. Appendectomy and lavage were performed. Patient was discharged on postoperative day 5, fully recovered, PCT level was normal and CRP showed downward trend.

During control visit, 2 weeks after surgery, patient didn’t have any complaints, wounds were fully healed without any sings of infection and abddominal ultrasound showed no pathology.Laparoscopic approach is propper even for perforated appendicits with diffused, purulent peritonitis is associated with faster recovery, lesser postoperative pain and lower surgical site inffection and should be procedure of first choice.



M. Milone, M. Manigrasso, G. de Palma Gastroenterology and Surgical Endoscopy, Federico II University, NAPLES, Italy

Background: We have designed a modified caudal-to-cranial approach to perform laparoscopic left colectomy preserving the inferior mesenteric artery for benign colorectal diseases.

Methods: IRB approval and informed consent have been obtained. A dissection is conducted to separate the descending mesocolon of the Gerota’s plan from the medial aspect to the peritoneal lining to the left parietal gutter. The peritoneal layer is incised parallel to the vessel and close to the colonic wall. The dissection is continued anteriorly up to reach the resected parietal gutter. A passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. These maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. A caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. It can be very useful to mobilize the colon in any direction: laterally, medially, or upward. The dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. The specimen is extracted by a pfannenstiel incision. The anastomosis is performed transanally with a circular stapler according to Knight-Griffin technique.

Results: We performed a laparoscopic segmental colectomy using this approach for 21 patients with benign sigmoid lesions: 13 diverticulitis, 3 flat polypoid lesions (no lift-up sign), and 5 bowel endometriosis. The mean operative time and blood loss were 161.4 ± 15.7 min and 50 ± 40 ml, respectively. There were not a single conversion to open surgery and no any leakage or stricture. Only 2 cases of intraluminal bleeding and 1 case of wound infection (treated conservatively) were observed.

Conclusion: We consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall.



E.J. Barzola Navarro 1, K. Ann Bob2, A. Glagolieva3, J.A. Flores Garcia1, G. Dapri4 1Digestive Surgery, Universidad de Extremadura, BADAJOZ, Spain; 2Department of Clinical Surgical Sciences, University of the West Indies, PORT OF SPAIN, Trinidad and Tobago; 3Surgery, PL Shupyk National Medical Academy, KIEV, Ukraine; 4Digestive Surgery, Hospital Saint Pierre, BRUSELLS, Belgium

Aims: To show a clinical case with a video of a patient was operated for colon cancer in hepatic angle by a single suprapubic incision (SSILRH).

Methods: A 44-year-old male assessed for abdominal pain and weight loss. On physical examination: a painful mass was detected in the upper right quadrant. The colonoscopy revealed an ulcerated lesion in the hepatic angle and the biopsy revealed a moderately differentiated adenocarcinoma. In the abdominal CT a mass of 3 x 4 cm was observed (figure). The patient was operated with SSILRH technique, as shown in the attached video.

Results: The patient was placed in the supine position and with the legs separated. The surgeon is placed between the patient’s legs. A transverse incision of the skin was made in the middle line of 3.5 cm to 1 cm above the pubis. The underlying fascia was divided transversely, the rectus abdominal muscle was exposed, a purse-string suture placed in the fascia. An 11 mm reusable trocar was inserted for the chamber, a 6 mm reusable flexible trocar was placed at the 9 o’clock position and another trocar was placed at the 3 o’clock position. The ileocecal valve was released from the peritoneal parietal foil, as well as the mesocolon right by a lateral to medial approach to the second portion of the duodenum. The hepatic angle was also dissected from lateral to medial. For the anastomosis, the 11 mm trocar was replaced with a 13 mm trocar and a stapler was placed. A 5 mm 30° chamber was inserted through the 6 mm flexible trocar. The small intestine was divided as well as the proximal transverse colon with EndoGIA. An intracorporeal ileocolic anastomosis was performed. The piece was removed through the suprapubic incision. He was discharged after 5 days without complications. The histological studies confirmed a differentiated adenocarcinoma of 8x7x6 cm. The surgical margins were free, without infiltrated lymph nodes (0/26) with stage pT3N0.

Conclusion: The SSILRH technique allows a complete resection of the mesocolon and complies with the oncological principles.



A.F. Aranzana Gómez1, J. Hernandez Gutierrez 1, J. Malo Corral, B. Muñoz Jimenez, A. Trinidad Borras, S. Abad de Castro, 1General Surgery, Complejo Hospitalario Toledo, TOLEDO, Spain; 2General Surgery, Hospital tres culturas, TOLEDO, Spain

Introduction and objectives: Giant colonic diverticula are infrequent lesions (10-15%). They can present with abdominal pain, nausea, acute abdomen, symptoms of intestinal obstruction or asymptomatic with incidental diagnosis. Their diagnosis can be difficult. The objective is to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology.

Material and methods: We present a video of the surgical intervention of a 32-year-old patient, with functional dyspepsia, with a casual diagnosis of a pseudocystic mass of the right colon after performing a CT scan: giant diverticulum of the hepatic colon angle with fecaloid content inside it under tension The patient goes to the emergency room for acute abdominal pain, pending colonoscopy, antibiotic treatment is established, and a laparoscopic approach is decided upon after the patient’s evolution.

Results: Intervention: complete laparoscopic approach, 4 trocars. Large size tumor in the right colon, diverticular in appearance, with stony content inside, with locoregional adenopathies, oncological radical right hemicolectomy, manual intracorporeal anastomosis, correct postoperative, hospital discharge. on the 4th day. Definitive pathological anatomy: giant diverticula on areas of intense mucosal ulceration, free edges.

Conclusion: The laparoscopic approach of the symptomatic diverticula of the right colon is safe and effective.



M. López Saiz, J. Riquelme Gaona, G. Rojas de la Serna, A. López Sánchez, M. Manzanera Díaz, F.J. Cortina Oliva, J. Gonzales Aguila1, C. Moreno Sanz Digestive Surgery, General Hospital, La Mancha-Centro, ALCAZAR DE SAN JUAN, Spain

Introduction: Minimally invasive transanal surgery (TAMIS) is a surgical technique whose established indications are the complete exeresis of rectal polyps that are not resectable endoscopically or early rectal neoplasms with good prognosis criteria. Transanal devices with gel platform facilitate dissection in this field. However, one of the drawbacks of this approach is the oscillation of the right nerve, which hinders dissection and prolongs the surgical time.

Material and methods: We present the case of a patient with a central depression neoformation, located 8 cm from the anal margin in the posterior aspect of the rectum in a male patient. The lesion occupies 25% of the circumference and was considered unresectable endoscopically. The endoscopic biopsies showed a tubulovillous adenoma with moderate dysplasia.

Results: An exeresis of full thickness of the rectal wall is performed, with subsequent suture of the defect. We show in the video the use of a glove interposed in the pneumoperitoneum gum to maintain the stability of the neumorectum and the technique of dissection and suture, as well as the stability of the neumorectum with this technique throughout the procedure.

Conclusion: The use of a glove as a reservoir to stabilize the nemorectum is an economical and easy-to-use method that can safely replace extra devices.



R. Bravo 1, A.M. Otero1, M. Gracia2, R. Martínez1, A.M. Lacy1 1Gastrointestinal Surgery, Hospital Clinic Barcelona, BARCELONA, Spain; 2Ginecology, Hospital Clinic Barcelona, BARCELONA, Spain

Aims: Endometriosis is a gynecologic disorder defined by the presence of endometrial glands and stroma outside the uterine cavity. Deep infiltrating endometriosis (DIE) invades 5 mm to the retroperitoneum of the pelvic sidewalls, the rectovaginal septum, or the muscularis of the bowel, bladder or ureters. The rectum is being the most common bowel site of involvement. For symptomatic DIE, medical therapy should always be the first-line treatment. Therefore, a minimally invasive approach using laparoscopy is considered the gold standard option and challenging aiming at complete disease excision. Also, there are several advantages of natural orifice specimen extraction when compared with abdominal incision that may directly impact the postoperative results of these young patients.

Methods: We report a case of a 36-year-old female with a 12-month history of chronic pelvic pain, dyschezia and rectal bleeding. These symptoms were refractory to hormonal, antispasmodic and opioid therapy. Magnetic resonance imaging reported a nodule 2 x 2 cm invading the rectal wall 10 cm to the dentate lane. We performed a laparoscopy and we found the nodule at the uterine posterior wall invading the rectal anterior wall. The nodule was invading into the rectum in a large area so we proceeded with segmental resection and added hysterectomy and salpinguectomy because it was the preference of the patient. The anastomosis was created intracorporeally and the specimen was removed through the vagina performing in this way a totally laparoscopic procedure with natural orifice specimen extraction.

Results: The total operative time was 3 h, the postoperative stay was uneventful and the patient was discharged on day four. The pathological report showed an endometrioma 4 × 4 cm length predominantly involving colonic muscularis propria.

Conclusion: Laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. In addition natural orifice specimen extraction avoids potential complications of abdominal incisions.



T. Nishida, H. Ikuta, K. Nishimura, T. Kudo Department of Surgery, Kasai City Hospital, KASAI CITY, Japan

Aims: The original Ripstein method of 1965, in which rectum was fixed posteriorly into the hollow of sacrum with T-shaped Teflon mesh tightly, showed good recurrence rate. However, the complications of rectal stenosis, constipation, mesh penetration and mesh infection were reported. Then in 1987, McMahan and Ripstein modified the original Wells method of 1962 to fix 1/2 back of rectum with rectangular Gore-Tex® sheet into sacrum, so as to reduce the complication of rectal stenosis. We that would know what shall be, must consider what has been. Therefore, we modified Ripstein method to keep good recurrence rate and get over the complications of original one. On the other hand, after the experience of 2 recurrent cases (8%) after 25 modified Wells method, we clarified the cause of and re-modified Wells method to overcome the recurrence.

Methods: We modified Ripstein method with T-shaped Bard®Mesh. Horizontal side was made 1.2 times longer than the circumference of rectum including mesorectum to prevent rectal stenosis after the mesh shrinkage of 7.7–18.9%. Vertical side was made 1.2–2 times longer than the original method to sustain rectum physiologically along sacrum. And more, we re-modified Wells method with rectangular Bard®Mesh. Horizontal side was prolonged 9–11 cm so as to cover 4/5 back of rectum and to be fixed accurately at sero-muscular tonic of ventral rectum. In both methods, mesh was fixed to sero-muscular tonic of ventral rectum with Endo Universal™Stapler, and was fixed to sacrum or pre-hypogastric nerve fascia with Endo Universal™ Stapler (former) and/or AbsorbaTack™(later).

Results: From February 2007 to October 2018, we underwent 100 rectopexies for complete rectal prolapse by 55 modified Ripstein, 25 modified Wells and 20 re-modified Wells methods. Pre/post-operative constipation was significantly reduced in every method. Pre/post-operative fecal incontinence was significantly reduced in re-modified Wells method. Recurrence rate were 0%, 8% and 0%, respectively.

Conclusions: Modified Ripstein method is adapted to super-aged (85) female and applied to whom combined with other POP. Re-modified Wells method is adapted to under-aged (85 >) female and male. We would like to continue 0% of recurrence rate in both methods forever.



A. Lo Conte 1, G.V. Cunsolo1, M. Pezzatini1, G. di Natale2, M. Gasparrini1 1Week-Day Surgery, University, Sapienza, Ospedale Sant’Andrea, ROME, Italy; 2Urology, Clinica Mater Dei, ROME, Italy

Aims: We describe a case of a patient affected by a mass in the left kidney and a diverticular stenosis of the sigma.

Methods: A 65 years old woman complained abdominal pain in the left flank of the abdomen and in the left iliac fossa radiated to the hypogastrium, with fever and no passing flatus. Contrast enhanced computer tomography scan (CT-scan) showed a 7 cm mass of the superior pole in the left kidney and a colonic diverticulitis with thickness of the wall and a microperforation of the sigma. She underwent to medical therapy with resolution of the diverticulitis. After 4 weeks a laparoscopic nefrectomy and sigmoidectomy was planned. Patient was positioned on the right flank. This position was kept for both the procedures. We performed four trocar accesses along the left subcostal region and a periombelical incision for the specimen extraction.

Results: Post-operative course was uneventful. Patient was discharged in 7 post-operative day. Istopathological exam showed a renal cell carcinoma confined to kidney with no positive lymph nodes and a diverticular stenosis of the sigma.

Conclusion(s): Laparoscopy allowed to perform two fine procedures in a critical situation using few trocar incisions and obtaining good results.



R. Bravo, A.M. Otero, R. Martínez, C. Gonzalez, R. Almenara, A.M. Lacy Gastrointestinal Surgery, Hospital Clinic Barcelona, BARCELONA, Spain

Background: Hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. Stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be at least considered in any case. Open restoration has been associated with significant morbidity and mortality. Many authors have described the advantages of laparoscopic Hartmann reversal. We want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique in a patient with 5 previous abdominal surgeries and a rectovaginal fistulae.

Methods: The transanal and laparoscopic team work simultaneously. By the abdominal approach a pericolostomic incision is made, the distal affected colon is resected and a purse string suture is performed around the anvil of the EEA 31 mm Single-Use stapler with 4.8 mm Staples (Autosuture, Covidien). A 12 mm umbilical trocar is located for a 30° camera and a GelPort Laparoscopic System (Applied Medical) with two 12 mm trocars is introduced through the colostomy wound. Hard pelvic adhesiolysis was performed and splenic flexure was also mobilized.The GelPoint path Transanal Access Platform (Applied Medical) is introduced through the anal canal with three trocars in a triangle position. The proximal rectum and mesorectum are dissected until the peritoneal reflexion. The previous stapler line with the resected tissue is then exteriorized throught the anus. The distal rectum is prepared with a circumferential purse string suture. The vaginal defect was sutured transanally. The proximal colon and the anvil are extracted through the rectal stump and connected to the circular stapler, performing an end-to-end anastomosis.

Results: The total operative time was 5 h. The postoperative stay was uneventful and the patient was discharged on day 5.

Conclusions: As in patients with rectal cancer, dissection of the stump in Hartmann reversal procedure may be better and associated with shorter operative time. As with any new surgical procedure, it is probably too early to draw conclusions but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a Hartmann reversal, especially in challenging cases.



A. Costanzi, E. di Fratta, M. Gerosa, A. Miranda, A. Rosato, G. Mari, V. Berardi, D. Maggioni General and Emergency Surgery, ASST Monza—Desio Hospital, DESIO, Italy

Introduction: Diverticular disease is widespread in Western countries due to diet and lifestyle. Diverticular perforation with abscess formation is a common complicaton of diverticulitis and, if untreated or misdiagnosed may lead to several degrees of morbidity.

Case Report: A 48 year-old male patient, BMI 43, presented in the ED with left lower abdominal pain, vomiting and slight fever for 3 days. On P.E. he showed rebound tenderness on left iliac fossa. Neuthrofil leucocytosis (21000 mm/c) and raised PCR (201 mg/dl) were present.

Intravenous and endoluminal contrast enhanced CT revealed the presence of a large retroperitoneal fluid and gas collection, due to diverticular perforation, extended from pelvis to iliac bifurcation, involving the left urether. No hydrosoluble contrast media leakage or massive pnuemoperitoneum were present. After an initial conservative treatment without significant improvement an emergency laparoscopic left colectomy with primary anastomosis and laparoscopic retroperitoneal collection drainage was performed. The laparoscopic approach was very challenging due to the obesity of the patient and the presence of the abscess.

The patient was discharged on POD 12 after requiring re-intervention for dehiscence of the left iliac mini-laparotomy on POD 7.

Conclusion: Diverticular perforation in obese patients adds a further challenge to its laparoscopic treatment and deserves an aggressive surgical approach since its outbreak.



P. Fabiano, E. Aycart General Surgery, Quiron salud Campo de Gibraltar, PALMONES, Spain

Although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. There are few studies comparing patients who underwent laparoscopic left colectomy with intracorporeal anastomosis or with extracorporeal anastomosis. Anyway literature shows that there is no significant difference between intracorporeal anastomosis and extracorporeal anastomosis about oncological result. As for right hemicolectomy, intracorporeal anastomosis seems to show a trend towards a faster recovery after surgery due to the shorter time to flatus and lower post-operative pain expressed in the mean VAS Scale. Laparoscopic left colectomy with intracorporeal anastomosis is associated with a lower rate of post-operative complications as for right colectomy. Literature results could suggest that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. As usual further randomized clinical trials are needed to obtain a more definitive conclusion. We show a video of a 58 years old patient with a pure splenic flexure colon cancer who underwent to a laparoscopic left hemicolectomy with intracorporeal anastomosis.



A. Predrag, A. Csengeri, C. Cremona General Surgery, Mater Dei Hospital, MSIDA, Malta

Background: Despite the low volume of surgical cases at Mater Dei Hospital—Malta, a significantly large proportion of patients are admitted with diverticulitis, equating to approximately 18 surgical admissions a week. The majority of these cases are simple non-complicated diverticulitis—which are managed conservatively with intravenous antibiotics and analgesia. However in the emergency setting, cases with higher Hinchey scores are managed surgically—either via radiologically guided drainage or in the eventuality of diffuse peritonitis with pus or intra-abdominal faeces—managed surgically via a Hartmann’s procedure. With the initiation of the emergency laparoscopic service locally in 2012 -an average of 85 laparoscopic emergency surgeries are being done per year by one surgical firm. A recent audit of the same firm, titled—’A study of post-operative complications in a General Surgery Firm in 2018’ showed that 14% of patients who underwent an emergency laparoscopic surgery experienced a Grade II or higher complications. (Clavien-Dindo Classification for Post-Operative Complications).

Case Presentation: Here we describe a case of a 81 year old asthmatic and hypertensive lady with an ASA score of III who presented to emergency after a right knee replacement with a four day history of lower abdominal pain. She was septic upon arrival to the resuscitation room—immediately prompting the hospital’s local septic management protocol. A CT scan of her abdomen showed a rectosigmoid perforation with free intra-abdominal air and fluid. The patient underwent laparoscopic Hartmann’s procedure within 4 h of admission. After an uneventful post-operative recovery the patient was discharged home after a total of 4 days of hospitalisation. She was followed up at surgical outpatients with no adverse events over the course of the subsequent months.

Conclusion: This case exhibits the feasibility of laparoscopic Hartmann’s procedure as a surgical modality for Hinchey Stage IV diverticulitis. The positive outcome supports the claim that for experienced surgeons Laparoscopic Hartmann’s procedure remains a safe and viable option for elderly comorbid patients in the emergency setting.



A.F. Aranzana Gómez1, J. Malo Corral 1, J. Hernandez Gutierrez1, A. Muñoz Tébar1, B. Muñoz Jimenez1, A. Trinidad Borras1, S. Abad de Castro2 1General Surgery, Complejo Hospitalario Toledo, TOLEDO, Spain; 2General Surgery, Hospital tres culturas, TOLEDO, Spain

Introduction: Mesenteric cysts are a very infrequent pathology, they usually present an anodyne clinic, and their diagnosis is reached casually.

Objectives: To demonstrate the safety and efficacy of the laparoscopic approach, in cases with intra-abdominal cysts of benign etiology, using material with mini-instruments, reducing surgical aggression, maintaining its safety and efficacy.Material and method: Clinical case: A 23-year-old man with no personal history of interest. In the last two months he presented episodes of pain in the right hypochondrium, exploration without findings, US-CT scan: a cystic tumor of 6 cm. in hepatic colon angle compatible with uncomplicated benign mesenteric cyst, tumor markers and normal colonoscopy. Evidence of interest is exposed. Given the evolution it is decided tto. elective surgical.

Result: Intervention: laparoscopic approach, 4 trocars, two of 3.5 MM, OPTICS OF 5 MM 30°, benign cystic tumor, with colloid content of more than 7 cm. of diameter in antimesenteric border of colon, which is not possible to separate, mobilization and resection is carried out by ENDOGIA, including a portion of the colonic wall, appendectomy, extraction in a pocket. Good postoperative course, alt to 2nd day. DEFINITIVE AP: Mesenteric cyst, absence of malignancy.

Conclusion: The laparoscopic approach is a valid and effective alternative in cases of benign intra-abdominal cystic pathology, the use of mini instruments reduces surgical aggression, favoring the recovery of the patient.



S. Giungato, A.S. Pepe Emergency Surgery and Endoscopy, Castellaneta Hospital, TARANTO, Italy

Aims: Bowel endoscopic prosthesis is a procedure applied worldwide for treatment of intestinal occlusion by neoplasm or inflammatory stenosis. In our emergency department we have tried to performe this technique for treatment of ultralow stenosis.

Methods: In our center we have performed endoscopic treatment of ultralow rectal stenosis with positioning of Ultraflex Precision Prosthesis, 25 mm x 8.7 cm. We have observed: complications; pain; fecal inctinence; well–being of patients; time of hospitalization.

Result: We have treated 2 patients with Ultraflex Precision prosthesis. 1 Male, 70 yr, wuth doblue post-operative coloanal stenosi and 1 Women, with ultralow rectal neoplatis stenosis (4 cm from anla verge). Both patients were discharge ater 3 days from prosthesis positionins without pain and complications. The first patient, with protection ileostomy, showed fecal incontinence before the operation and was performed prosthesis positioning because rectal losses of infected material and fever. Fecal incontinence was showed also after procedure but he had not fever. Second patient, 93 yr, with ultralow rectal tumor, after prosthesis positioning was submitted to radiotherapy and she decided for not to be operated and she survives after 6 months in ful well-being.

Conclusion: Endoscopic prosthesis positioning is a consolidated procedure for treatment of bowel obstruction. This study demonstrated that this procedure is safe and this kind of prosthesis is suitable for correct positioning.



N. Mestres Petit, J.E. Sierra Grañon, C. Cerdán Santacruz, M. Santamaría Gómez, J. Escoll Rufino, M. Rufas Acin, J. Ortega Alcaide, J.J. Olsina Kissler Department of Surgery, Hospital Arnau de Vilanova, LLEIDA, Spain

Aims: To remark the feasibility of TAMIS for treatment of big rectal lesions without invasive signs.

Methods: Single case video of TAMIS for rectal adenoma with high grade dysplasia.

Results: We present a case of a 67 years old man with faecal occult blood test positivity that was diagnosed by colonoscopy of a villous lesion at 9 cm of anal verge. Biopsies were taken showing a tubulovillous adenoma with high grade dysplasia. A rectal MRI was done showing the lesion fixed to the postero-lateral left side of the lumen at 9 cm of anal verge. No pathological lymph nodes were reported. Extension study was negative. The case was presented in multidisciplinary committee agreeing in local excision. In October 2018 the procedure was done without incidents. The patient was placed in lithotomic position finding a lesion occupying of the lumen. Resection was done without incidents and posterior suture with 2 continuous barbed sutures. He presented an uneventful recovery being the patient discharged in 3rd postoperative day. Definitive pathological findings showed a pTis with negative margins. After three months of follow-up the patient remains with good functional results and waiting for the first endoscopic revision.

Conclusions: TAMIS is a safe and feasible technique with low morbidity that gives us an alternative for early rectal cancer or big rectal lesions much less invasive than techniques used until now.



A. Rabal Fueyo 1, J. Bollo Rodriguez1, D. Sacoto1, M. Solans Solerdelcoll1, C. Martinez Sánchez2, N. de la Fuente1, E.M. Targarona Sole12 1General Surgery, Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain; 2Colorectal Surgery, Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

Complete mesocolon excision and D3 lymphadenectomy are two fundamental points in the oncological surgery of right colon cancer. Most of the adenopathic recurrences of colon neoplasia in tumors located in the hepatic angle and the ascending colon are located near the head of the pancreas and the vascular axis of the superior mesenteric vein due to an alleged incomplete dissection.

We present a case of right colon neoplasia where we performed a laparoscopic right hemicolectomy associated with a D3 lymphadenectomy. We use medial to lateral dissection of the mesocolon focused on the dissection of the superior mesenteric vein with the identification of ileocolic vascularization, right colic vessels and Henle’s trunk. This approach is safe and facilitates a correct resection of the mesocolon, which is approached following the embryological plans and a vascular ligature near the bifurcation.

The performance of an extended lymphadenectomy allows a wider resection of the mesocolon and the excision of a greater number of lymph nodes, all of which can contribute to a greater survival.



M.P. Gutierrez Delgado1, J. Carrasco Campos1, A. Rodríguez Cañete 2, S. Mera Velasco1, J. Gonzalez Cano1, M. Pitarch Martinez1, A. Titos García1, J. Moreno Ruiz1, I. González Poveda1, M. Ruiz López1, J.A. Toval Mata1, J. Santoyo Santoyo1 1Cirugía General y Digestiva, Hospital Regional de Málaga, MALAGA, Spain; 2Esofagogástrica, Hospital Regional de Málaga, MALAGA, Spain

Aim: The aim of this study was to evaluate the role of fluorescence imaging using an injection of indocyanine green (ICG) 24–36 h before laparsocopic surgery, in the detection of peritoneal carcinomatosis (PC) due to colorectal cancer (CCR).

Background: Peritoneal metastasis (PM) occur in 30-40% of patients with CCR. Cytoreductive surgery (CS) followed by hiperthermic intraperitoneal chemotherapy (HIPEC) is the only potentially curative option in patients with limited PC. This treatment results are comparable to results obtained in patients surgically treated for liver metastases.

Fluorescence imaging guided surgery can improve tumor detection. ICG has been shown to be useful for identifying small subclinical tumors that were not identified at surgical exploration.

Cases: Two patients who was diagnosed of CCR 2 and 5 years ago and who went under sigmoidectomy surgery, a CT scan of follow-up showed peritoneal nodule suggestive of PM. ICG, at 0’25 mg/kg of patient weight, was intravenous injected 24–36 h before surgery. Exploratory laparoscopy was the selected approach in these cases, in one of them we could find under standard white light, a small liver tumor and a peritoneal nodule in left lower quadrant, both of them hyperfluorescent by infrared camera system. In the other case, ICG showed us a peritoneal metastasis on the small bowell. No more lesions were found in the abdominal cavity, and HIPEC was applied.

Results: Nodules were hyperfluorescent, and all of them were malignant. Both patientes, are currently undergoing chemotherapy and follow-up by Oncology.

Conclusion(s): The efficacy of PC treatment is related with a properly preoperative imaging diagnosis of the disease, but the poor sensitivity for identifying small peritoneal metastasis are the major obstacle to achieve a complete resection and that leads to peritoneal recurrence. Image-guided surgery using ICG, could represent an advance in the detection of small peritoneal nodules. There are only a few clinical studies that have analyzed the role of ICG for the staging of PC, specially from CCR, and nearly in all of them the selected approach were exploratory laparotomy. This study presents a laparoscopy case, as a non-invasive way of CS in selected patients with limited PC.



M. Delgado Morales 1, R. Pérez Quintero2, P. Rodríguez González2, N. Cisneros Cabello2, J. Guadalajara Jurado2 1Cirugía General, Hospital Infanta Elena, HUELVA, Spain; 2Cirugía General, Hospital Juan Ramón Jiménez, HUELVA, Spain

Aims: Mucinous appendiceal neoplasms (MAN) are rare, and they are detected in 0.2–0.3% of appendectomy specimens.

A new category, Tis, was created for low-grade appendiceal mucinous neoplasms (LAMNs) that invade or push into the muscularis propia by AJCC Cancer Staging 8th Ed. Management of these tumors depends on stage and histology.

Traditionally, laparotomy was the most recommended approach, however, if laparoscopy is safe, it could be used. The laparoscopic appendectomy should be done with ‘not touch’ technique and a radical approach has been recently proposed for its treatment.

The laparoscopic radical appendectomy should start by exploring complete abdominal cavity. Grasping of appendix should not be done. Complete resection of mesoappendix is obligated. Cequectomy with stapled endoGIA is necessary. The specimen must be extracted in an endobag.

Methods: We report a case of a 64 year-old female patient with a personal history of three caesarean sections.

This patient was studied due to chronic abdominal pain. A computerized axial tomography was performed, showing an appendix increased in size and a thick wall. The colonoscopy evidence a lesion that protrudes from appendiceal base which is biopsied.

Results: A laparoscopic way was used and large and width appendiceal was viewed (10x2 cm). Furthermore, a rounded right anexial tumor was also found. A radical not touch laparoscopic appendectomy with stapled cequectomy was done. The intraoperative study was mucinous appendiceal tumor without serose affection. The final result was pTisNx (LAMN) without resection margins affected.

After 48 h of admission, the patient is discharged without incidents.

Conclusion(s): Minimally invasive surgery in LAMNs is possible if it is performed with enough experience, following specific rules and tips to manage this tumors. A correct follow-up should be carried out using tumor markers and computer tomography (CT).



M. Abdeldayem, C. Matthews, P. Blake, B. Gwilym, L. Maw, A.G. Masoud

Colorectal Surgery, Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

Introduction: Resection of both benign and malignant colovesical fistulae can be particularly challenging and carry with it specific surgical considerations. Often there is a large inflammatory mass sat within a narrow pelvis, limiting specimen mobility and consequently access to dissection plains. Additionally, with the underlying inflammatory process, the ureters may be displaced anatomically and be at risk of injury.

Aim: To demonstrate a streamlined and reproducible approach to the laparoscopic management of both benign and malignant colovesical fistula, with specific emphasis on the different modalities for bladder repair.

Method: The following method portrays an overall technique which is adapted dependant on the clinical scenario and specific intra-operative findings:

Approach to abdominal cavity in standard fashion.Identification of right ureter.Poster-medial mobilisation of the mass to facilitate delivery out of the pelvis followed by Visualisation of the left ureter on the medial AND lateral sides before division of the fistula.Division of the fistula in benign disease or resection of the bladder dome in malignant disease.Transverse laparoscopically sympathetic suprapubic skin incision.Vertical incision through Linea Alba to deliver bulky specimen.Intra/extracorporeal repair of bladder dome.

Results: All of the considered cases were successfully completed with a laparoscopic approach, irrespective of the malignant status of the disease in question.

Conclusion: Both benign and malignant colovesical fistula disease can make the laparoscopic approach to resection challenging, especially when encountering a bulky mass in a narrow male pelvis. The stepwise and streamlined approach considered here can help facilitate successful and safe laparoscopic completion without the necessity to convert to open.



J. Ye Zhou, M. Solans, N. de la Fuente, M.C. Martinez, M.P. Hernandez, J. Bollo, E. Targarona Cirugia General y Digestiva, Hospital de la Santa Creu i Sant Pau, BARCELONA, Spain

Background: Primary neoplasms of the retrorectal space are very rare. They are located in anatomically difficult area to be addressed, hence a complete evaluation of the lesion is required to determine the extent of resection and the appropriate surgical approach, which include posterior, abdominal and combined abdominoperineal, depending on the characteristics of the lesion.

Objective: to show a combined laparoscopic abdominoperineal approach of retrorectal tumor. Method: we present a video of a combined laparoscopic abdominoperineal resection of a low-lying retrorectal tumor in a 73-year-old female without prior abdominal surgery.

Conclusion: Retrorectal tumors are infrequent. Their anatomical location can make difficult the surgical approach. Preoperative imaging can provide useful information for surgical planning. In the recent years, minimally invasive surgical approach has been proposed. Laparoscopic approach is feasible and safe, but it is important to select adequately the patients.



M. Abdeldayem, K. Thippeswamy, A. Joseph Colorectal Surgery, Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

Background: Adult intussusception is a rare clinical event representing only 1–5% of all bowel obstruction cases and 5% of all intussusceptions and the occurrence of adult intussusception due to colonic cancer is even more rare.

Aim: we present this case of malignant colo-colic intussusception and literature review to increase the awareness of the incidence of colocolic intussusception due to colonic cancer.

Case report and Literature review: Our patient is a 70 years old female was admitted to our hospital due to central abdominal pain, CEA level of 4, She was further investigated with CT scan of the abdomen and pelvis which raised the suspicion of mid transverse colon intussusception due to large polypoid lesion. She was further assessed with urgent colonoscopy which confirmed mid transverse colon tumour with biopsies confirmed adenocarcinoma. Laparoscopic extended Right hemicolectomy with lymph node dissection was performed. Upon laparoscopic exploration it was found that the colocolic intussusception was evident as described on the CT scan and as clearly shown on the video. Histologically, the transverse colon carcinoma was a moderately differentiated adenocarcinoma, with no lymph node involvement ‘0 out 15 lymph nodes’, TNM staging of pT3 pN0 pM0 and R0 resection.

Intussusceptions of the colon in adult are frequently found in the ileocecal portion or sigmoidal colon but rarely in the transverse colon. Only two cases of adult intussusception of the transverse colon caused by colonic cancer have been reported. Overall 12 cases on literature review reported showing colo-colic intussusception due to colonic malignancy.

Conclusion: Colo-Colic intussusception due to colorectal cancer is a rare clinical event, however it should be included in the differential diagnosis of colonic obstruction. Laparoscopic surgery is safe in malignant colocolic intussusception.



T.H. Wang, T.C. Chang, Y.T. Chen, T.Y. Hsu Department of Colorectal Surgery, Taipei Medical University-Shuang Ho Hospital, NEW TAIPEI CITY, Taiwan

Aims: Single-incision laparoscopic colectomy (SILC) aims to achieve better cosmetic outcomes, less pain, and faster recovery compared to multi-port laparoscopic colectomy, but it also has several limitations, especially the technical difficulties. We report our experience with single-incision robotic right hemicolectomy via video presentation.

Methods: We arranged robotic-assisted single-incision right hemicolectomy for a 78-year-old female patient with ascending colon tumor. The operation was performed with Gloveport single-port device and a three-arm da Vinci robotic surgical system through a small midline umbilical incision. Colectomy was proceeded by a medial-to-lateral approach along with one or two accessory instruments for maintaining sufficient bowel traction or surgical field exposure. After vessel ligation, complete colon mobilization and right side omentum division, the robotic arms were undocked to perform anastomosis extracorporeally.

Results: The operation was performed successfully without drainage tube placement. The total operative time was 193 min. The bowel movement returned on post-operative day 5,and the patient tolerated normal soft diet on post-operative day 7. She was hospitalized for 8 days after operation. The pathology report revealed colon adenocarcinoma (T1N0M0, tumor size 1.8 cm), and 19 lymph nodes were harvested.

Conclusions: Single-incision robotic colectomy (SIRC) approach seems feasible and safe in treatment of ascending colon cancer. This surgical option provides less pain and wound scar for the patient. Moreover, it also achieves further benefits for the surgical procedures compared to SILC. Reasons being, first, it has better instruments flexibility and precision with endo-wrist, as well as less instruments clashing. Second, the improved camera stability achieved through the use of the robotic arm is unattainable through manual hand-controlled methods. Third, robotic-assisted approach gives us an ergonomic environment, which enables the operator to control the arms while sitting by the console, and also to reassign them whenever they cross each other or block the surgical view. In spite of the advantages above, we still need to sincerely consider each patient’s situation for proper management.



C. Santi 1, L. Casali2, C. Franzini2, A. Rollo2, V. Violi1 1Surgery, Hospital of Fidenza, University of Parma, FIDENZA (PR), Italy; 2Surgery, Hospital of Fidenza, FIDENZA (PR), Italy

Recently, Indocyanine Green (ICG) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.The aim of our study is the application of ICG imaging during laparoscopic colorectal resections: to identify sentinel lymph node, for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear and to assess anastomotic perfusion to reduce the risk of anastomotic leak.

After tumor identification 5 ml of ICG solution (0.3 mg/Kg) is subserosal peritumoral injected. A Full HD IMAGE1 S camera, switching to NIR mode, in about 10 min displays fluorescence: the SLN is identified and the SLN biopsy (SLNB) is performed.When tumor is in difficult site, as hepatic or splenic flexure, 5 ml of ICG solution (0,3 mg/Kg) is intravenous injected. In about 30–50 s a real-time angiography of tumor area is obtained; on this guide, vascular dissection and pedicle ligation is performed.After anastomosis, another 5 ml of ICG solution is injected to confirm anastomotic perfusion. If there is an ischemic area, a new anastomosis is performed.

From November 2016, 70 patients were enrolled: 22 left colectomy, 38 right colectomy, 2 transverse resections, and 8 resections of splenic flexure. In ten cases, intraoperative angiography led to the identification of vascular anatomy. In two cases the anastomotic perfusion wasn’t good and the surgical strategy was changed. Four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. From November 2017, 40 patients were enrolled to perform the SLNB: 23 right colectomy, 11 left colectomy, 1 transverse resection and 5 splenic flexure resections. The SLN was identified in 37 cases. 17 cases were found to be N0 to the conventional examination and were subjected to ultrastaging. ICG-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. It’s recommended to reduce the incidence of anastomotic leak, to facilitate the assessment of vascularization in order to perform oncological resections, and to perform the SLNB to study its clinical role on nodal status and for the SLN ultrastaging in order to identify the micrometastases.



J. Azevedo, C. Ordonez, B. Vailati, G. São Julião, R. Oliva Perez Colorectal, Angelita and Joaquim Gama Institute, SÃO PAULO, Brazil

Background: Surgical emptying of lateral pelvic lymph nodes (LLND) is a strategy used differently when compared the approaches to rectal cancer in the west and eastern countries. There is evidence that = 5 mm lymph nodes in lateral compartment should be removed, even in the setting of neoadjuvant chemoradiation. Minimally invasive surgery with nerve-sparing technique and sharp dissection with minimal bleeding may help overcome the significant complexity of the procedure that may have been a technical obstacle to implementation in the past. The standardization of the technique may help implementation with shorter learning curves and excellent surgical outcomes.

Methods: A 56-year-old male with distal rectal cancer underwent neoadjuvant CRT for a mrT3cN2M0 mrEMVI + mrCRM + disease. There was one left obturator node of 7 mm prior to CRT. Following 12 weeks of CRT completion, the patient underwent taTME for the primary disease followed by left lateral node dissection by laparoscopy.

Results: The present video illustrates the most relevant surgical steps to perform lateral node dissection. The procedure has been didactically divided into 7 steps. The left ureter is identified and retracted using a vessel loop (Step 1). Identification of the common iliac vein and dissection with subsequent identification of psoas and internal obturator muscles (Step 2). Identification and dissection of accessory vessels. (Step 3) Identification of obturator nerve and obturator vessels (Step 4). Blunt dissection of obturator nerve (Step 5). Identification and ligation of obturatory vessels. (Step 6) Umbilical artery is skeletonized to allow identification and clearance of fatty tissue along superior vesical arteries, internal iiliac artery/vein, inferior vesical artery and internal pudendal artery (Step 7). Postoperative course was uneventful.

Conclusion: Standardization of lateral-node dissection for rectal cancer has paramount importance. Laparoscopic lateral-node dissection for rectal cancer provides optimal anatomical view and allows safe dissection of the nodes of interest.



G.P. Martin-Martin, J.M. Olea, L. Fernandez, A. Ochogavia, M. Fernandez, J.J. Segura, N. Alonso, M. Gamundi, X. Gonzalez Colorectal, Hospital Universitario Son Espases, PALMA, Spain

Aims: The aim of this video is to describe our technique using fluorescence to assess the lymph flow to ensure a complete mesocolic excision and central vascular ligation in order to provide expertise to contribute to the standardization of this new tool.

Methods: Laparoscopic right colectomy with total excision of the mesocolon was proposed in all cases. For the detection of lymph flow, we injected indocyanine green dye (1 milliliter of 25 milligrams dye dilution in 10 milliliter of distilled water) into the subserosal to submucosal layer around the tumor at 1 point with a 21-gauge injection laparoscopically after trocar insertion, and observed the lymph flow using a near-infrared system (Visera Elite II, Olympus) after injection. We also performed a total mesocolic excision with central vascular ligation in the region where the lymph flow was fluorescently observed.

Results: 7 (100%) patients were included. No intraoperative or postoperative complications presented. No adverse effects were reported due to the infusion of indocyanine green. The lymph flow was visualized intraoperatively in a satisfactory way helping the surgeon in decision making to determine an appropriate separation line of the mesentery. The section line of the mesocolon was modified in 1 (14%) case based on the findings obtained by fluorescence. The mean operative time was 160 (42) min. The morphometric laboratory data of the specimens to audit the correct complete mesocolic excision were satisfactory according to the oncological standards.

Conclusion: Fluorescence lymphography during colorectal surgery was feasible and reproducible with a minimum of added complexity. Fluorescence-guided surgery may be a helpful technique for determining an appropriate total mesocolic excision in colon neoplasms.



M. Ballabio, S. Macina, M. de Francesco, L. Baldari, A. Spota, S. Petrucci, M. Della Porta, E. Cassinotti, L. Boni General Surgery, Ospedale Policlinico di Milano—Università degli Studi di Milano, MILANO, Italy

Aims: This video shows our technique for complete mesocolic excision (CME) during right colectomy for cancer.

Methods: In this video, a 62 years old patient underwent a laparoscopic right colectomy with CME for a cancer of the ascending colon diagnosed with a colonoscopy performed after positivity to fecal occult blood test (FOBT). After CT scan staging we obtained 3D printed models to clarify patient’s vascular anatomy. Patient was placed in supine position, 4 trocars were inserted in left quadrants as for standard right colectomy. CME is performed by sharp dissection between the visceral fascia that covers the posterior lay of the mesocolon and the parietal fascia that covers the retroperitoneum (Toldt’s fascia). The ileo-colic vessels are used as landmark to identify the right anterior surface of the superior mesenteric vessels. With a caudo-cranial approach, the mesocolon is sharply dissected and the root of tributaries venous is ligated, up to the inferior margin of the pancreas. The gastro-colic trunk is dissected out with ligation of the right colic vein, while the gastroepiploic vein is preserved (harvesting the sixth group lymph node). The pancreas-duodenum fascial plane is entered and all the lymphoid tissue around the vessel surface is harvested. Procedure is completed with ileo-transverse intracorporeal stapled anastomosis.

Results: In our experience, between April 2017 and December 2018, 46 laparoscopic right hemicolectomies with CME were performed. We had no major intraoperative vascular lesions. No patients needed intraoperative blood transfusion. Compared to our series of standard right colectomies we did not notice any significant difference in post-operative complications. The follow-up is too short to demonstrate if the CME approach has a better oncological outcome compared to standard right colectomy.

Conclusions: Laparoscopic CME is feasible, although it requires a higher expertise level of surgical know-how. The quality of evidence is limited and does not consistently support the superiority of CME as compared to standard right colectomy. Better data are needed before CME can be recommended as the standard of care for colon cancer resections.



H. Bando Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, KANAZAWA, Japan

Aim: In case of right-sided transverse colon cancers, it is necessary to dissect the lymph nodes around the root o f the middle colic vessels. But in this area there are dangerous organs, for example : pancreatic head, duodenum, and gastrocolic trunk. It is the point of our technique that we resect the accessory right colic vein and middle colic vein, and then dissect pancreas head and duodenum at early step of the operation.

Method: We perform the operation by five trocars. The first step is to transect the great omentum, and confirm the lower edge of pancreas.There are much adhesion between mesocolon of transverse colon and stomach, great omentum. It is very important to dissect the adhesion accurately. Secondly, the mesocolon is incised at lower edge of pancreas. It is possible to detect the lower edge of pancreas in obese people. The anterior surface of superior mesenteric vein is exposed. The accessory right colic and middle colic vein are resected. And then front face of surgical trunk, pancreas, and duodenum is dissected caudally as possible. The superior mesentery artery is resected below the mesocolon after flip up of transverse colon. This approach is safe and feasible, because the dangerous organs are handled by direct vision. By that, extraction of intestine is easy from small incision. Afer flip up of transverse colon, the mesenteric of ileum is incised. The root of ileocecal vessels is exposed and these are resected. The peritoneum of the front of superior mesenteric artery is incised, and the lymph nodes around the surgical trunk are dissected. This dissected area is easily connected with the one done beforehand. Uniquely we resect the mesocolon and major omentum from the root of dissected vessels to resected side of transverse colon. And then right-side colon is dissected medial approach.

Conclusion: We dissect the dangerous organs in advance. That prevent major injury of them.



J. Waterman 1, M. Abdeldayem1, D. Brown2, P.N. Haray3 1Colorectal Surgery, Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom; 2Digimed®, ESSEX, United Kingdom; 3Colorectal Surgery, University of South Wales, WALES, United Kingdom

Background: Good visualisation of the operative field is a fundamental requirement for safe laparoscopic colorectal surgery. Over the past 25 years of the senior author’s experience, camera systems have evolved from single to three chip, High Definition (HD) and most recently, the 4 K system. In parallel, the rest of the infrastructure such as cables, processors, monitors etc. have also undergone improvements, resulting in improved image quality.

Aim/Methods: We present a video of a case of Laparoscopic Total Mesorectal Excision (TME), performed with strict adherence to our previously published ‘Stepwise Approach to Laparoscopic Colorectal Surgery’ which places particular emphasis on safety aspects. TME was performed in a 54 year old male patient with history of previous abdominal as well as robotic prostatic surgery. The procedure was filmed with all components including the camera head, cables, processing unit, screens as well as the recording/mixing decks being 4 K. Multiple external 4 K cameras were also used. Live transmission to a remote audience as part of our masterclass was achieved using appropriate bandwidth and projection on to 4 K screens.

Results: Feedback from the operating team as well as from the live audience was that the image quality was far superior to HD systems. The 4 K system accorded a degree of clarity well beyond usual expectations. The depth of field also appeared to be different initially, but within a few minutes of starting the procedure and acclimatisation, the effects were appreciable. The clarity of the image which showed the fine details of the dissection planes and anatomical landmarks as well as the vibrancy of the vasculature gave a distinct three-dimensional effect to the picture. This excellent visualisation added one more layer of safety and complemented our stepwise approach for a successful procedure.

Conclusion: The laparoscopic 4 K system, in our practice, proved to be a beneficial visualisation tool to enhance the accuracy of dissection. Vital structures appeared to be more vivid and clearer with dissection planes being more easily apparent. In our opinion the Laparoscopic 4 K system when combined with a systematic approach enhances safety, especially in complex laparoscopic colorectal surgery.



H. Takahashi 1, M. Miyoshi1, H. Haraguchi1, T. Hata1, M. Chu1, Y. Yamamoto1, M. Mizushima1, M. Mori2, D. Yuichiro1 1Gastroenterological Surgery, Japan / Osaka University Graduate School of Medicine, SUITA, OSAKA, Japan; 2Department of Surgery and Science, Kyushu University, FUKUOKA, Japan

Accumulating evidence suggests that laparoscopic surgery for colon cancer has feasibility and efficacy equal to or over conventional laparotomy. For cases with pasthistory of laparotomy, especially history of colon resection, however, there is almost no evidence for laparoscopic re-colectomy for metachronous colon cancer.

Since 2016, we have been used submucosal local injection of indocyanine green (ICG) around primary colorectal cancer by using intraoperative endoscopy, and complete mescolic excision (CME) have been convincingly carried out, which was clarified by completely resected ICG positive area. Although evidence on the oncological efficacy of ICG guided surgery has not yet been clarified, since it can be easily judged whether CME is performed clearly, it is considered that ICG guided surgery for primary colon cancer is useful for education.

Recently, we are applying this to ensure convincing CME for patients with colorectal cancer who had a history of colic resection. The representative case is as follows. A 60-year-old female was diagnosed as advanced sigmoid colon cancer, and laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery was performed 10 years ago. Then she was diagnosed as the metachronous descending colon cancer. The feeding artery of the new tumor should be the left colic artery, however, the left colic artery was already resected and genuine feeding artery was not identified by preoperative examination. By injecting ICG into submucosa endoscopically during operation, it was clearly observed that the lymphatic flow from the tumor was directed to the inlet portion of the inferior mesenteric vein (IMV). Re-CME was performed by ligating the inlet of IMV. Intraoperative ICG was also useful for clarifying the borderline for adhesion detachment of pastoperation between the mesentery and retroperitoneum (Figure). Interestingly, ICG flow in the mesentery direct to of the anus side was disrupted clearly at the past anastomotic site.

We believe that laparoscopic surgery under ICG guidance is potential useful tool that can confirm evidence to date more intuitively in real time. Further studies, ideally randomized controlled trials, are required for define the oncological usefulness of ICG guided surgery for re-do colectomy. The operation movie will be presented at the meeting.



Z. Liu, X.S. Wang Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, BEIJING, China

Background: Laparoscopic lateral pelvic node dissection (LLPND) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. In this video, we demonstrate the technique of LLPND for rectal cancer patients with suspicion of LLN metastases after neoadjuvant chemo-radiation.

Methods: The principle of this approach is en bloc resection with bilateral peritoneum. The peritoneum is incised lateral to the ureter following the line between external and internal iliac vessels. In the next step, LLPND dissection of the regional lymph node and high ligation of inferior mesenteric vessels were performed. A contralateral LLPND was performed in the same manner as a mirrored technique. After extracting the specimen, an end-to-end double-stapled circular anastomosis was performed.

Results: The procedure was done safely without any complications.The surgical duration was 245 mins, and the blood loss was 50 mL. The number of harvested lateral pelvic lymph nodes was 15. The TNM stage was ypT4aN2M0.

Conclusion: This approach enables extended resection during lymph node dissection, allowing autonomic nerve preservation. It is maybe a helpful approach in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis.



M. Kryzauskas 1, T. Poskus1, M. Jakubauskas1, A. Dulskas2, E. Poskus1 1Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, VILNIUS, Lithuania; 2Surgery department, National Cancer Institute, VILNIUS, Lithuania

Aims: The aim is to present an inspection method where the anastomosis vascularity is testing simultaneously using the indocyanine green fluorescent angiography intraluminal and intraperitoneal.

Methods: Sixty-five year old female patient underwent standard laparoscopic-assisted low anterior rectal resection for rectal carcinoma. The proximal end of the bowel and the stump of the distal rectum were checked using near-infrared fluorescence imaging with D-Light camera. After making sure of adequate perfusion of the bowel, the end-to-end stapled anastomosis was performed under the laparoscopic visualisation. The D-port proctoscope was inserted into the anus. The second ICG injection was administered. The perfusion of the anastomosis in transabdominal way and viability of the mucosa in transanal way was evaluated with two D-Light cameras simultaneously. The anastomosis was determined 4 cm from the anal verge. An air-water leak and tension of the bowel tests were performed. After evaluation of anastomosis viability with fluorescence imaging, after negative air-water leak and tensions testing, the decision was made by surgeon not to perform preventive ileostomy.

Results: The patient had no complains for the first three days postoperatively. Nevertheless, CRP level was growing and was 69.6 mg/l on the second postoperative day, and 103.5 mg/l on the 4th postoperative day. The patient complained of the pain in the right iliac area and below symphysis on the 4th postoperative day. The abdominal and pelvis computed tomography scan with oral contrast was performed which denied our thoughts about the anastomotic leakage. Intravenous cefuroxime and metronidazole antibiotics were prescribed. The CRP level was 16.3 mg/l on the 10 th postoperative day. The patient was discharged on the 11 th postoperative day without preventive ileostomy.

Conclusion: Using the original, standardized colorectal anastomosis inspection method we can determine which patient doesn’t need the preventive ileostomy after low colorectal anastomosis.



Z.Z. Mamedli, S.S. Gordeyev, K.E. Dzhumabayev, I.S. Tatayev Colorectal cancer, N.N.Blokhin Russian Cancer Research Center, MOSCOW, Russia

The 2 important causes of anastomotic leak are local ischemia and staple line defect. The purpose of this study was to investigate the combination of methods aimed to reduce the risk of anastomotic leak after anterior resections for rectal cancer.

Methods: We retrospectively analyzed perioperative outcomes of the first 30 patients, who underwent modified laparoscopic anterior resection with partial mesorectal excision for rectal cancer without preventive stomy. Operative technique was modified and included routine preservation of the left colic artery (fig1)(aimed to improve anastomotic blood supply), manual suture invagination of the ‘dog ears’ (fig2) (aimed to reduce the risk of staple line defects), transperineal pelvic drainage and pelvic peritoneum reconstruction (aimed to reduce the risk of reoperation in case of leakage). Anastomotic leak rate, reoperation rate, left colic artery preservation rate, additional operative time (time required for left colic artery preservation, ‘dog ears’ invagination and pelvic peritoneum reconstruction), blood loss, morbidity and mortality were analyzed.

Results: 1 (3.3%) patient developed an asymptomatic leakage, which was managed conservatively. There was no postoperative mortality and no reoperations. Median additional operative time was 56 min for the first 15 procedures and 41 min for the last 15 procedures. Left colic artery preservation was successful in 26 (86.7%) patients. Median blood loss was 35 ml.

Conclusions: Additional techniques used in our modification of laparoscopic anterior resection are safe and may lead to improved perioperative outcomes. However, they are associated with increased operative time, which may be reduced with a better learning curve.



M. Abdeldayem, C. Matthews, P. Blake, B. Gwilym, L. Maw, A.G. Masoud Colorectal Surgery, Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom

Introduction: Parastomal hernias are a significant cause of post abdominal ostomy morbidity with an overall life-time incidence exceeding 80%.

The complications can range from a bulge resulting in stoma bag leakage, to life threatening bowel obstruction. The PREVENT-trial sought to determine if prophylactic utilisation of polypropylene mesh would decrease the incidence of parastomal hernias, with initial results demonstrating that it was safe to use in permanent end stomas.

Aim: To demonstrate a reproducible and streamlined technique for laparoscopic parastomal hernia repair with intraperitoneal funnel mesh, and assess the outcomes with the Clavien-Dindo (CD) classification tool.

Method: 10 parastomal hernia repairs (7 colostomy, 3 ileostomy) were considered, with the following approach adopted for each:

Swab sutured in stoma orifice to prevent wound contamination.Sharp dissection of the stoma using parachute technique.Stoma end refreshed followed by change of gloves and instruments.Lateral stay sutures placed to tighten sheath later on.Pneumoperitoneum temporarily created to assess/divide adhesions.Funnel mesh placed in-situ, orientated in the optimal intra-abdominal position, and sutured to the peri-colic fat to prevent slip.Medial suture placed to narrow the sheath further.Pneumoperitoneum re-created and mesh fixed in place with double crown laparoscopic tacks.Redundant portion of end stoma excised and stoma formed.

Results: At median follow up of 12 months:

No Recurrence.No reported symptoms of pain or decreased stoma functionality.One superficial wound infection treated with drainage at bedside (CD = Grade 1)

Conclusion: Laparoscopic parastomal hernia repair with intraperitoneal funnel mesh for permanent end stomas yielded good outcomes in our patient cohort. A streamlined and reproducible approach ensures that the technique can be adopted for both prophylactic, primary and recurrent repair. Parastomal hernias are common and can be associated with significant morbidity. When taking this into account, in conjunction with the recommendations of the initial results of the PREVENT-trial, one may consider prophylactic utilisation of a mesh in patients receiving a permanent end stoma.



E. Kakiashvili 1, E. Brauner2 1General Surgery, Galilee Medical Center, KIRIAT MOZKIN, Israel; 2General Surgery, Rambam Medical Center, HAIFA, Israel

29 year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy.

During last year, patient suffered from recurrent episodes of ascending cholangitis. Recently, she underwent ERCP and severe stricture of middle CBD was diagnosed. Plastic stent was inserted through the CBD. MRCP also showed severe stricture of CBD with dilatation of biliary tree, proximal to the stricture.

Due to severe and resistant (did not resolved by recurrent dilatation) structure of middle CBD, she was referred to operation.

Patient underwent da Vinci robot-assisted excision of the CBD stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of Roux-an-Y limb.

Total operating time was 320 min. Day three after operation patient started regular diet and was discharged home on day four.

Final pathology has shoved part of CBD with severe inflammation.



E. Falsetti, T. Cipolat Mis, M.C. Cartillone, A. d’Alessandro, E. Chouillard General And Minimally Invasive Surgery, Poissy-Saint-Germain-en-Laye Medical Center, POISSY, France

Aims: Extrahepatic biliary duct resection for the treatment of Bismuth I and II stage Klatskin tumor is the standard surgical technique [1].

Methods: A 85 years old patient present at Emergency Room (ER) with right upper abdominal pain with an elevation of the inflammatory markers at the blood exams and fever. The patient was submitted to a computer tomography (CT) that shows a tumor involving the lower tract of the principal bile duct.

An endoscopic retrograde cholangio pancreatography (ERCP) with biopsy (Intraductal papillary neoplasm of the bile duct,IPNB with high-grade dysplasia) and stent placement was performed.

Considering the good general conditions of the patient and an absence of vascular and nodal invasion at the preoperative imaging, a minimally invasive surgical resection of the biliary tract with cholecystectomy was performed.

Results: A four port laparoscopic biliary tract resection with cholecystectomy was performed with lymphadenectomy of the hepatic hilum. No vascular or liver infiltration was found. The hepatic hilum was completely skeletonized. The resection of the biliary duct was performed with adequate free margin. A biliary reconstruction with Roux-en-Y technique was performed and a fully laparoscopic hepatico-jejunal anastomosis was done. And abdominal retro anastomotic drain was placed. The operative time was 350 min. The postoperative course was complicated by a low rate biliary leakage that was treated conservatively. The patient was discharged at 25 post operative day in good general conditions.

The histological examination revealed a moderately differentiated in situ cholangiocarcinoma of the principal bile duct with the involving of the cystic duct with free resection margin (pT1bN0R0).

Conclusions: Laparoscopic resection of the biliary tract is a challenging procedure that allows, in expert hands, to achieve in selected cases negative pathological margin, complete linfonode retrieval and entero-biliary bypass.

[1] Hilar cholangiocarcinoma: diagnosis, treatment options, and management Kevin C. Soares1, Ihab Kamel2, David P. Cosgrove3, Joseph M. Herman4, Timothy M. Pawlik1.



Y.S. Han, J.R. Han, H.T. Ha Hepatobiliary Pancreas Surgery and Liver Transplantation, Kyungpook National University, School of Medicine, DAEGU, Korea

Injury to the extrahepatic bile duct during bile duct or hepatic surgery can be reduced by better real-time visualization. Recently, indocyanine green (ICG) fluorescence imaging has been used in laparoscopic hepatobiliary surgery. We applied ICG fluorescence imaging in patient with huge hepatic cyst which severely deviated extrahepatic bile duct. The patient had received laparoscopic cholecystectomy and huge hepatic cyst stuck firmly with peri-hepatic structures including bile duct. ICG fluorescence imaging correctly identified the common hepatic duct and remnant cystic duct and allowed for more meticulous and easier dissection. Therefore, ICG fluorescence imaging may guide a safe and accurate dissection and excision in hepatobiliary surgery.



E. Kakiashvili 1, E. Brauner2 1General Surgery, Galilee Medical Center, KIRIAT MOZKIN, Israel; 2General Surgery, Rambam Medical Center, HAIFA, Israel

63 years old, female patient presented with recurrent right upper quadrant (RUQ) pain, without fever, nausea or vomiting.

30 years ago, patient underwent open cholecystectomy due to cholelithiasis. During last four years, she suffered from recurrent attacks of biliary colic or ascending cholangitis.

Patient several times underwent ERCP and extraction of stones from common bole duct (CBD).

At her last admission, ultrasound (US) revealed recurrent large stones in CBD with significant dilatation of extra and intra hepatic biliary duct (CBD up to 2 cm).

Her blood laboratory examinations showed mild elevation of bilirubin and liver functional tests (LFT’S).

Patient underwent da Vinci robot-assisted choledochotomy, extraction of CBD stones and choledochoduodenostomy.

Total operating time (ORT) was 240 min. Two days after operation patient started regular diet and was discharged home on day four.



A.L. Vargas Ávila, A.F. Palacio Vélez, G. Diazteran Aguilera, J. Garcia Cansino, V.G. Reyes Garcia, K.B. Molina Tavarez, J. Vargas Flores, J.F. Nagore Ancona, J.M. Hernandez Garrido, C.A. Cortazar Sanchez, N.N. Espinosa Queb, L.A. Guerrero Galindo, J.A. Dominguez Rodriguez, J.A. Gonzalez Luna, A. Jimenez Leyva, J. Sanchez Lora, S.J. Salgado Arzate, A. Castañeda Rodriguez Cabo General Surgery, ISSSTE, CIUDAD DE MEXICO, Mexico

Aims: To report a serie of cases of LCBDE (laparoscopic common bile duct exploration) after failed ERCP (endoscopic retrograde cholangio pancreatography) in our hospital from January 2009 to June 2018

Methods: A retrospective cohort analysis was perform. Inclusion criteria were: a) Diagnosis of choledocolthiasis by clinics, imagenology and biochemestry measures. The variables were: Age, gender and tecnique employed: Cholecystectomy plus LCBDE, primary or recidivant choledocolithiasis, primary closure of choledocotomy, use of T-tube or transcistic catether; Intrahospital days and Morbimortality.

Results: Total patients who underwent ERCP were 2,321 and 3.2 percent (75 cases) had a first failed ERCP and 13 of then were unsuccesfull in the second intent of ERCP. Intrahospitalary stay was more than 7 days in the 11 percent, in the 89.2 percent was 4 to 7 days, with and average of 6 days.

Conclusions: Before, during or after LCBDE, ERCP remains the gold standard for manegement of Choledocolitiasis confirmed by clinics, laboratory and imagenology.

LCBDE is a very good option that requires experience and specific skills, and especialized equipment.

In 9 years the rate of sucess in our hospital was 95.3% and there were no posoperatory complications such as: Biliar peritonitis, pancreatitis or liver abscess.



G.P. Martin-Martin 1, X. Molina2, A. Pozo3, E. Palma2, J.M. Moron2, X. Gonzalez1 1Colorectal, Hospital Universitario Son Espases, PALMA, Spain; 2Hepatobiliopancreatic, Hospital Universitario Son Espases, PALMA, Spain; 3Imaging, Medical Systems Division, Olympus Iberia, BARCELONA, Spain

Aims: Easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared (NIR) fluorescence imaging after an injection of indocyanine green (ICG). Neither radiological support nor additional intervention such as opening the cystic or common bile duct is required, making it an easy and real-time technique to use during surgery. The aim of this video is to describe our experience in fluorescence-guided cholangiography in different clinical situations.

Methods: Intravenous injection of ICG is used to illuminate extrahepatic biliary anatomy. However, the simultaneous enhacement of liver parenchyma can disturb the visualization of clinical details. The key is in the used dose of ICG, the route of administration and the time since its infusion. In the first case, a scheduled cholecystectomy is shown in which a dose (1 mL of 25 mg dye dilution in 10 mL of distilled water) administered intravenously 3 h before the intervention was used. The second case shows an urgent cholecystectomy in which the dose (30 mL of 25 mg dye dilution in 1000 mL of distilled water) was administered intragallbladder during surgery. All patients underwent laparoscopic cholecystectomy with traditional four-port technique. All procedures were performed using a 30-degree 10 mm laparoscope with NIR imaging capability (Visera Elite II, Olympus).

Results: There were no intraoperative or postoperative complications. There was no increase in operative time due to the use of ICG. In the first case, a clear identification of the cystic duct and the main bile duct was obtained thanks to the biliary excretion of the ICG and the intravenous clearance. In the second case, the identification of the cystic duct, the main bile duct and the cystic artery occurred due to the intravesicular absorption of ICG.

Conclusion: Fluorescence-guided cholecystectomy clarifies the dissection plane. It can be considered to increase the safety of laparoscopic cholecystectomy. Being aware of the doses, times and possible routes of administration is basic to universalize the technique and give it utility in different scenarios.



A.L. Vargas Ávila, A.F. Palacio Vélez, J. Garcia Cansino, G. Diazteran Aguilera, V.G. Reyes Garcia, K.B. Molina Tavarez, J. Vargas Flores, J.F. Nagore Ancona, J.M. Hernandez Garrido, C.A. Cortazar Sanchez, N.N. Espinosa Queb, L.A. Guerrero Galindo, J.A. Dominguez Rodriguez, J.A. Gonzalez Luna, A. Jimenez Leyva, J. Sanchez Lora General Surgery, ISSSTE, CIUDAD DE MEXICO, Mexico

Introduction: Mirizzi syndrome type 2 is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in Hartmann’s pouch or the cystic duct with a resultant cholecystocholedochal fistula. The obstructive biochemical changes can be caused by direct extrinsic compression from the impacted gall stone or from the fibrosis caused by advanced chronic cholecystitis, or for the established fistula.

Objective: We present a case of a Mirizzi type 2 syndrome with choledocholithiasis which was solved by laparoscopy approach.

Material and Methods: A 28-year-old female patient with no past medical history. The history of present illness begans with the presence of icteric dye since the last 3 days; she received symptomatic treatment with poor improvement. A liver and biliary tract ultrasound was performed with report of a 12 mm coledochus, 5 mm wall gallbladder. Then an endoscopic retrograde clolangiopancreatography was performed with successful endoscopic sphincterotomy and removal of gallstones. But the patient jaundice persisted after the procedure. The patient underwent cholecystectomy and laparoscopic common bile duct exploration, where the findings were a Mirizzi type 2 according to the Csendez classification, chronic cholecistitis and choledocholithiasis.

Results: In this laparoscopic approach we performed a partial cholecystectomy, bile duct exploration with removal of residual gallstones. The closure of the choledocotomy was performed with simple knots using vycril 3.0. A subhepatic drainage was left. The patient showed adequate clinical evolution. After 4 days the patient was discharged.

Conclusions: It is important to properly identify the anatomy at the time of surgery to avoid injury of the common bile duct. Operative treatment of Mirizzi syndrome type 2 includes either laparoscopic or open subtotal cholecystectomy or placement of a T-tube or choledocoplasty.



A. Pesce 1, T.R. Portale2, B. di Stefano2, G. la Greca3, S. Puleo4

1Department of Medical, Surgical Sciences and Advanced Technologies ‘G.F. Ingrassia’, University of Catania, CATANIA, Italy; 2Dpt of Medical, Surgical Sciences and Advanced Technologies „G.F. Ingrassia„, University Hospital „Policlinico-Vittorio Emanuele„, CATANIA, Italy; 3Department of Medical, Surgical Sciences and Advanced Technologies,, CATANIA, Italy; 4Department of Medical, Surgical Sciences and Advanced Technologies, University Hospital Policlinico, CATANIA, Italy

Near-infrared fluorescent cholangiography (NIRF-C) is an innovative intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. Thanks to the development of laparoscopes/endoscopes with light sources emitting infrared frequencies, it is possible to visualize anatomical structures (vessels, ureters, bile ducts, etc.) through the luminous intensity of substances (fluorescein, blue of methylene, indocyanine green) which are injected into the patient. This technology may be considered as an important teaching tool for laparoscopic surgery, especially for young surgeons in their surgical learning curve and it could lead to reduce the risk of iatrogenic bile duct injuries during laparoscopic cholecystectomy. The following video is characterized by a series of intra-operative images of biliary anatomy by fluorescence, having an important educational interest, while also detecting anatomical variations of the cystic duct.



A. Umezawa Minimally Invasive Surgery Center, Yotsuya Medical Cube, TOKYO, Japan

Aims: Laparoscopic cholecystectomy(Lap-C) for cholecystolithiasis has become standard. However, serious bile duct injury has been reported as a complication. Repeated colic and chronic inflammation in cholecystolithiasis lead to the so-called Difficult Gallbladder conditions, such as dense fibrosis and scarring of the tissue. Dissection of Calot’s triangle includes the risk of bile duct injury. Critical View of Safety (CVS) is the most well-known land mark for safe cholecystectomy. In the revised Tokyo Guidelines 2018 (TG 18), important land marks and bailout procedures had been proposed. Those are for the Difficult Gallbladder which are not able to achieve CVS.

Methods land marks: Baseline of segment4 of the liver and sulcus Rouvier should be confirmed. The gallbladder wall itself is also useful landmark. Bailout procedure: When the dissection of Calot’s triangle is considered impossible, bailout procedures should be considered. Subtotal cholecystectomy which leave the neck is one of option. The fundus first technique is another approach. However, because fundus first technique has a possibility of leading to serious bile duct injury, it should stop by the neck. In this video, first case shows the importance of landmarks from near miss cases of misidentified injuries. Second Case shows bailout procedure, subtotal cholecystectomy with fundus first technique.

Result: In the atrophic gallbladder (case 1, near miss), it is liable to misidentify the junction of common bile duct as the gallbladder neck. The neck and common hepatic duct were lifted together easily. With confirming the landmark, misidentification was corrected and bile duct injury was avoided.In the case2, since the Calot’s triangle was obscured due to repeated cholecystitis, dissection of gallbladder was performed from the bottom to the neck, and was excised with the cervical portion remained. The remaining neck was reconstituted.In each case, intraoperative cholangiography was performed, and it was confirmed that there was no bile duct injury. Without postoperative complications, those patients were discharged POD 2 as usual Lap-C.

Conclusion: During Lap-C for difficult gallbladder, the most annoying part is bile duct injury. Confirming landmarks and switching bailout procedures can be contributory to avoid bile duct injury and to achieve safe Lap-C.



R.J. Costa, H.R. Fonseca, L.A. Graça, E.J. Maia, Cirurgia Geral, Centro Hospitalar Universitário de São João, PORTO, Portugal

Aims: Choledocholithiasis is an important cause of morbidity and is present in about 18% of patients submitted a cholecystectomy. His treatment should be done in the same operative time, avoiding the morbidity and hospitalization time and costs of multiple procedures.The transcystic approach is preferable to prevent morbidity associated to choledochotomy.Large stones can preclude this procedure. The use of laser lithotripsy to stone fragmentation is an option to provide transcystic extraction.

Methods: We present a video of Laparoscopic Transcystic Common Bile Duct (CBD) Exploration for Choledocholithiasis.

Results: Female patient, 65 years old with a previous hospitalization for acute cholangitis with choledocholitiasis.Submitted to laparoscopic cholecystectomy with intraoperative cholangiography that showed the presence of stone in distal CBD with 1 cm size. The use of Holmium laser lithotripsy made the stone fragmentation and provided his extraction by transcystic route using a basket.The patient was discharged at 4th postoperative day, with no complications.

Conclusion: The use of laser lithotripsy for large CBD stones is safe and effective, making possible the transcystic approach and preventing the choledochotomy morbidity.



G.F. Faria, J.P. Gonçalves, A.F. Cocco, A. Cabral-Correia, A.M. Gouveia Surgery, ULS Matosinhos / Hospital Pedro Hispano, MATOSINHOS, Portugal

Gallbladder adenocarcinoma is rare and extremely aggressive. Its’ incidence is higher in elder females and its progression is rapid and silent with a dismal prognosis if diagnosed at advanced stages.

We present the case of a 77 years-old female with dyspeptic complaints. The abdominal ultrasound revealed a 2 cm solid lesion of the gallbladder suspect for malignancy. The CT confirmed the presence of a vegetant mass on the free border of the gallbladder fundus with 28x13 mm.

We performed a radical cholecystectomy with lymphadenectomy and liver bed excision. The post-operative period was complicated with a urinary tract infection, with full recovery after antimicrobial treatment. The histological sample revealed an adenocarcinoma of the gallbladder (T1bN0M0) and the patient remains asymptomatic and tumour free 9 months after the surgery.

Gallbladder cancer treatment depends of the stage and clinical presentation of the disease. Complete surgical excision is the only curative treatment and should include a limited hepatectomy and portal pedicle lymphadenectomy. Laparoscopic surgery might be an option in early stages, although it is challenging and requires both expertise in hepato-biliary and laparoscopic surgery.



J.I. Ortiz de Elguea Lizárraga, M. Rodarte, G. Arredondo, J. Rojas Surgery, Tecnologico De Monterrey, SAN PEDRO GARZA GARCÍA, Mexico

We present a clinical case of a 34 year old female without any past medical history.

Seen at the emergency room for a two month history of abdominal pain associated with jaundice.

She is evaluated by the surgical team and diagnosed with acute cholecystitis and moderate risk for choledocholithiasis. The initial surgical plan was cholecystectomy with intraoperative cholangiogram.

During surgery, firm adhesions are found from the gallbladder to omentum. Friable tissue with edema and easy bleeding. Difficulty is encountered during the dissection of Calots’triangle. An intraoperative cholangiogram is done through Hartmans’pouch without identifying correctly the biliary tract. Therefore, an endoscopic retrograde cholangiopancreatography (ERCP) is done to visualize the correct anatomy.

During the ERCP, a stenotic common hepatic duct is found and no stones are visualized. A biliary endoprosthesis is placed. She is discharged asymptomatic.

A month later, the patient is back in the emergency room with abdominal pain. After an abdominal CT scan, we found that the endoprosthesis had migrated to the 4th portion of the duodenum.

A second ERCP is done and this time we found a big stone (1.5–2 cm) in the common biliary duct. Basket and lithotripsy are done without success. A new endoprosthesis is placed.

A new ERCP is done this time with SPYGLASS. Using the SPYGLASS, the big stone was destroyed and the biliary tract cleared.



C. Blajut, C. Cirlan, I. Budrugeac, M. Iordache-Petrescu, M. Iordache, F. Savulescu General Surgery II, Dr. Carol Davila Central Military Emergency University Hospital, BUCHAREST, Romania

Aims: When training in the residency you watch your teacher perform laparoscopic cholecystectomy with ease, and even yourself perform several steps. But as a young surgeon, when confronted with a patient with acute cholecystitis, you’re filled with emotions, and you do not know where to start the gallbladder dissection. The aim of this presentation is to show to young surgeons that you can, and must achieve, critical view of safety when performing laparoscopic cholecystectomy for acute cholecystitis.

Methods: We present the case of a 42 years old female patient, BMI of 36.3, who presented with a grade II (moderate) acute cholecystitis. Following Tokyo Guidelines, we initiated antibiotics and general supportive care, but without clinical improvement. The patient was proposed for laparoscopic cholecystectomy.

Results: At initial exploration we identified a 20 cm long gallbladder, with a thick wall, difficult to manipulate. We opted for an anterograde cholecystectomy, in our opinion the best option in acute cholecystitis. The dissection was started with hook electrocautery and then continued with a combination of blunt dissection with the aspirator and with the hook. When reaching the pedicle, blunt dissection was used in order to appreciate the anatomy of the cystic duct and cystic artery. After correct identification of these structures they ware clipped and cut. A drainage tub was then placed, and the abdomen deflated.

Conclusion(s): As a young surgeon, when dealing with acute you must maintain your calm, and try to achieve critical view of safety before transecting the cystic duct and cystic artery. This can be achieved with a combination of blunt and sharp dissection, keeping your camera clean and with a good collaboration with the assisting surgeon.



H. Konstantinidis, C. Charisis Robotic General and Oncologic Surgical Department, Interbalkan Medical Centre, THESSALONIKI, Greece

Aims: Several tactics of safe dissection and identification of the Callot’s triangle structures during a laparoscopic cholecystectomy have been proposed, with the ‘critical view of safety’ technique being the most accepted. Thus, in complicated cases, this approach is not always feasible and many surgeons turn to the retrograde cholecystectomy technique, in order to overcome the difficulties of the dissection. Our aim is to highlight the risks that may rise from that approach in complex cases of laparoscopic cholecystectomy.

Methods: We present video fragments of a laparoscopic cholecystectomy procedure in a case of acute cholecystitis, with gallbladder abscess and plastron, in which a retrograde approach was decided. We emphasize on the possible risks that this technique encapsulates and the mandatory surgeon’s awareness, in order to avoid major complications.

Results: The retrograde cholecystectomy technique in cases of complex cholecystitis with severe inflammation can falsely misguide the surgeon to porta hepatis dissection. Considerable experience and proper operative strategy is required to avoid major incidents in these cases.

Conclusions: Difficult and sometimes impossible proper dissection of the Callot triangle during a laparoscopic cholecystectomy, oblige many surgeons to retrograde cholecystectomy technique. Severe inflammation may mislead a surgeon to the porta hepatis during this approach, occurring a very high risk of major vascular and extra-hepatic biliary injuries. All surgeons who decide to utilize this particular technique should be aware of these risks and the strategy to overcome them.



B.J.G.A. Corten 1, W.K.G. Leclercq2, P.H. Zwam3, R.M.H. Roumen2, G.D. Slooter2 1Surgery, MMC Veldhoven, EINDHOVEN, The Netherlands;2Surgery, MMC, EINDHOVEN, The Netherlands;3Department of Pathology, PAMM, EINDHOVEN, The Netherlands

Background: The Dutch Surgical Society changed its national ‘gallbladder’ guideline 2016, regarding routine histopathologic examination after cholecystectomy in absence of macroscopic abnormalities. Thus, shifting the macroscopic examination of the gallbladder from the department of Pathology to the operating room. The surgeon is now asked to perform a macroscopic examination of the gallbladder, and decide whether additional histopathologic assessment is warranted. Up to this date, there is no clear guideline or protocol to perform a proper surgical examination. Leaving surgeons extemporaneous in regard to selective histopathologic gallbladder examination.

Methods: The present study describes a surgical approach for adequate macroscopic inspection of the gallbladder. This procedure was introduced in 2011 and implemented in 2012 following an evaluation of the existing literature in collaboration with the department of Pathology.

Results: Since incorporation of the selective policy we have performed over 2000 surgical macroscopic examinations of the gallbladder. As a result, we observed a significant decrease in histopathologic examination of the gallbladder following cholecystectomy. Whereas we observed a stable trend of gallbladder carcinoma in the same period.

Conclusions: Here, an easy and reproducible method is described for future macroscopic analysis by the surgeon following a cholecystectomy. In addition, we depict several frequent macroscopic abnormalities in order to provide surgical colleagues with some cases of abnormal macroscopic gallbladders.



H. Cristino, V. Gomes, M. Almeida, L. Graça, J. Costa-Maia Hepato-bilio-pancreatic, Centro Hospitalar são joão, PORTO, Portugal

The left hepatectomy is a demanding and difficult procedure, still limited to reference centers. The caudal approach and exposure of the middle hepatic vein is a reliable way to achieve a safely and reproductible left hepatectomy.

With this technique, exposing the middle hepatic vein, we believe that we can perform a safe and feasible laparoscopic left hepatectomy increasing the quality of this hepatectomy.

We present a 47-year-old woman with an intrahepatic and common bile ductlithiasiswhich was previously submitted to an ERCP. With an unsolved intrahepatic lithiasis the patient was proposed to alaparoscopic left hepatectomy.



F. Ratti, F.C. Cipriani, G.F. Fiorentini, A.L. Aldrighetti Hepatobiliary Surgery Division, San Raffaele Hospital, MILANO, Italy

The minimally invasive approach for ALPPS in a patient with a large hepatocellular carcinoma in a liver with severe steatosis is shown. During the first stage a partial ALPPS is performed. PVE is performed in postoperative day one. After 15 days from the first stage both liver volume and function (by HIDA scan) are re-assessed. Right hepatectomy (second stage of ALPPS) is then conducted by laparoscopic aproach.



H. Cristino, V. Gomes, M. Almeida, L. Graça, J. Costa-Maia Hepato-bilio-pancreatic, Centro Hospitalar são joão, PORTO, Portugal

A 68 year old woman with a previous history of anxiety and catheter ablation to treat heart arrhythmias, was studied for for multiple pancreatic cysts incidentally discovered on a routine ultrasound.

An MRI was performed showing multiple cystic tumors throughout the pancreas, the largest of which was 15 mm. This led to a suspicion of multi-focal, side-branch intraductal papillary mucinous neoplasm (IPMN), with minimal dilatation of the main pancreatic duct. An Echo endoscopy was subsequently performed indicating probable multifocal IPMN. A FNA was carried out during this procedure, with aspiration of cystic content which was sent for CEA analysis and cytology. Cytology was compatible with mucinous neoplasm with mild atypia and CEA 98 U/ml.

A splenic preserving total laparoscopic pancreatoduodenectomy was proposed. The procedure was uneventful and the patient was discharged on the 5th post-operative day. Pathology revealeded a 19 mm IPMN, with severe dysplasia and 3 foci of microinvasive ductal adenocarcinoma of 1 mm—pT1N0R0.



Y. Tai Department of Surgery, E-Da Hospital, KAOHSIUNG CITY, Taiwan

Obtaining negative tumor margin during laparoscopic hepatectomy has always been a very challenging topic for surgeons in that the surgeons are not able to palpate the tumor during laparoscopic surgery. Although intra-abdominal echo is available, but it demands great experiences and skills. With the guidance of ICG immunofluorescence, surgeons can avoid failure of not obtaining enough negative margins nor resect too much healthy liver.

ICG is often used to estimate the liver function prior to hepatectomy traditionally. It binds to plasma protein and has a peak absorbance at 780 nm and emits fluorescence with a wavelength of approximately 800 nm. ICG is preferentially retained in or around biliary malignancies due to impaired biliary excretion of hepatocytes in the affected area.

We performed ICG immunofluorescence guided laparoscopic partial hepatectomy on a 57 years old male who suffers from HCC located at segment 5 and 6. ICG was injected 3 days prior to the operation day. While evaluation of liver is performed, it also allowed us to use a high-end laparoscopic camera system equipped with integrated filters for detection of near-infrared fluorescence. During the surgery, we were able to clearly locate the borders of malignancies through the use of integrated filters combine with ICG injection. The pathology study also confirmed that the adequate tumor free margin (> 0.5 cm) were obtained in both tumors and the patient’s condition was stable as well.

ICG immunofluorescence guidance enables surgeons to obtain optimum result in tumor resection through laparoscopic surgery. It also has the ability to detect bile leakage. With the use of ICG immuofluorescence, surgeons will have higher chances to achieve adequate negative margins.



R. Pena 1, F. Riquelme2, C. González1, C. Fondevila2 1General Surgery, Hospital Clinic, BARCELONA, Spain; 2Hepatobiliopancreatic Surgery, Hospital Clinic, BARCELONA, Spain

Background: Parenchymal sparing hepatic resection has the advantage of preserving valuable tissue in chemotherapy-treated livers, assuring an adequate future remnant volume without compromising long-term survival. Moreover, the laparoscopic approach offers the decreased postoperative morbidity of minimally invasive surgery. Whenever technically feasible, this kind of procedure should be considered a suitable alternative to the classic major hepatectomy for the treatment of multiple colorectal liver metastases.

Methods: 69-year old male with a previous history of laparoscopic sigmoidectomy in November 2014 for a pT2N0M0 sigmoid adenocarcinoma. A control scanner three years later showed liver metastases in segments V, VIII, II and caudate lobe. After chemotherapy (XELOX), control MRI and PET scans showed a good response. He was proposed for a laparoscopic parenchymal-sparing liver resection.

Results: Total operative time was 3 h and 45 min with no intraoperative complications. Patient presented a right atelectasis as the only postoperative complication and was resolved with respiratory therapy. He was discharged in 4 days. Pathology report showed that lesions on segment V and VIII had no viable tumor (100% fibrosis) and lesions on segment II and caudate lobe had moderately differentiated adenocarcinoma. Margins were free in all the lesions. After a 6 month follow up, the patient has no recurrence and normal liver function tests.

Conclusion: Minimally invasive liver resection is possible in patients with multiple bilobar liver metastases and allows to perform parenchymal-sparing surgery safely. Difficult localization of lesions such as the caudate lobe are not a contraindication for this type of surgery.



E. Kakiashvili 1, E. Brauner2 1General Surgery, Galilee Medical Center, KIRIAT MOZKIN, Israel; 2General Surgery, Rambam Medical Center, HAIFA, Israel

A 30 years old, female patient presented with recurrent right upper quadrant (RUQ) abdominal pain (during last two years), without nausea, vomiting or jaundice. Her blood laboratory examinations were within normal limits, including serum CA 19-9.

Ultrasonography (US) demonstrated a large cystic dilatation of common bile duct (CBD). An abdominal computed tomography scan (CT) and MRCP revealed a type I choledochal cyst, measuring 3.5 cm in diameter.

Patient underwent da Vinci robot-assisted excision of the type I choledochal cyst, hepaticojejunostomy and extracorporeal jejuno-jejunostomy of Roux-an-Y limb.

Total operating time (ORT) was 325 min. Three day after operation patient started regular diet and was discharged on day fife.

Pathology result confirmed choledochal cyst without evidence of malignancy.



F. Ratti, F.C. Cipriani, G.F. Fiorentini, A.L. Aldrighetti Hepatobiliary Surgery Division, San Raffaele Hospital, MILANO, Italy

Laparoscopic approach for perihilar cholangiocarcinoma is still poorly reported in the literature due to technical challenges secondary to the combination of major hepatectomy, lymphadenectomy and biliary confluence resection. Despite this, in selected cases it can be a good option to provide a short term benefit to patients. The video reports the case of a perihilar cholangiocarcinoma with involvement of left bile duct and therefore requiring left hepatectomy.



Y. Ome Hepato-Biliary-Pancreatic Surgery, Komagome Hospital, BUNKYO-KU,TOKYO, Japan

Aims: Segmentectomy is an anatomic liver resection, in which the tertiary branches of the Glissonean pedicles are selectively transected. However, the branching pattern of the tertiary branches varies depending on the case, particularly in segment 7 (S7) and segment 8 (S8). The extrahepatic approach to the Glissonean pedicle from the hepatic hilum is very difficult depending on the branching pattern. Furthermore, the distance of exposing the secondary branches that are to be preserved becomes longer, and there is an increased risk of biliary leakage and delayed biliary stricture due to excessive traction in laparoscopic surgery. Therefore, laparoscopic S7 and S8 segmentectomy are considered technically difficult. We standardized the intrahepatic Glissonean Pedicle Approach for laparoscopic S7 and S8 segmentectomy.

Methods: We standardized the intrahepatic Glissonean Pedicle Approach for laparoscopic S7 and S8 segmentectomy. We identify the targeted Glissonean pedicle intrahepatically after the parenchymal transection along the major hepatic vein or its branch running on the intersegmental plane, referring to the preoperative simulation by 3D imaging. (a)S7 segmentectomy; After the mobilization of the right lobe, the Glissonean pedicles of S7 (G7) can be approached from the dorsal side by transecting the parenchyma between the IVC and the right hepatic vein. After the division of the G7, the parenchyma is transected along the demarcation line and the RHV from the root side to the peripheral side. (b)S8 segmentectomy; First, the parenchyma is transected along the middle hepatic vein (MHV) from the root side to the peripheral. G8 is typically detected on the right dorsal side of the MHV. After the division of the G8, the liver parenchyma is transected along the demarcation line and the RHV from the root side to the peripheral side.

Results: We have experienced 11 cases of laparoscopic S7 segmentectomy and 26 cases of laparoscopic S8 segmentectomy.

Conclusion: Our approach to the G7 and the G8 is safe and very useful.



J.H. Kim Department of Surgery, Eulji University Hospital, DAEJEON, Korea

Laparoscopic anatomical segmentectomy of right anterior section is technically demanding because it is difficult to dissect the deep tertiary branches of right anterior portal pedicle (RAPP). We present three cases of laparoscopic anatomical segmentectomy using the extrafascial and transfissural approach: 1) anatomical resection of segment 5, 2) anatomical resection of the ventral area 3) anatomical resection of segment 8 dorsal area.

The extrafascial and transfissural approach means that the liver parenchyma along the fissure lines is opened, then the surgeon can confirm the Glissonean pedicles and territory directly. The extrafascial and transfissural approach in laparoscopic anatomical segmentectomy of right anterior section is feasible and effective because this technique can easily be approached to the deep tertiary branches of RAPP.



Y. Iimuro, A. Takano, Y. Tsukahara, K. Ikegame, H. Watanabe, K. Mastuoka, K. Furuya, M. Yasutome, M. Hada, Y. Miyasaka Surgery, Yamanashi Central Hospital, KOFU, Japan

Repeated liver resection has significant role in patients with recurrent hepatocellular carcinoma (HCC) in several situations. Laparoscopic redo surgery is becoming safer along with advance in surgical technique. We have performed laparoscopic re-resection for limited intrahepatic HCC recurrence. The Aim of the present study was to investigate its significance comparing with first laparoscopic liver resections.

Subjects: Patients with limited intrahepatic HCC recurrence after open hepatectomy underwent laparoscopic liver re-resection (n = 12).

Methods: Adhesion between abdominal wall and visceral organs was carefully divided, after the first laparoscopic port was safely inserted. Adhesion between diaphragm and liver surface or between previous liver cut surface and colon or duodenum was also minimally dissected. Approach to the Glisson’s pedicles at the hepatic hilum was often difficult due to previous surgical procedure, thus Pringle’s maneuver was generally applied. Dissection of hepatic parenchyma approaching to the target Glisson’s branch was often preceded under the ultrasound-guidance. Liver resection was performed using LCS, BiClamp, and CUSA using intermittent block of the hepatic inflow. Operation time, intraoperative bleeding, morbidity, mortality, and postoperative hospital stay were compared with those in patients who underwent first laparoscopic liver resection during the same period (n = 20).

Results: Operation time was significantly longer in the re-resection group, possibly due to the adhesiolysis. Meanwhile, no significant difference was detected in intraoperative bleeding, morbidity, mortality and postoperative hospital stay between the first and the redo surgeries.

Conclusion: Laparoscopic liver re-resection seemed comparable to the first laparoscopic resection except for longer operation time. Considering the invasiveness of open hepatic re-resections, laparoscopic re-resection of HCC in selected patients is possibly feasible method.



S.H. Choi, J.W. Lee Surgery, Bundang CHA Medical Center, SEONGNAM-SI, Korea

Introduction: Indocyanine green near-infrared fluorescence image help determine the correct anatomical resection of the liver parenchyme as well as the exact point of the bile duct division. This video demonstrates the technique of pure laparoscopic living donor right hepatectomy and usefulness of the indocyanine green fluourescence image.

Methods: The donor was a 32-year-old gentleman who decided to donate part of his liver to his wife suffering from viral liver cirrhosis and hepatocellular carcinoma. His BMI was 20.3 kg/m2 and the preoperatively estimated donor’s right liver volume was 836 ml, representing 63.6% of his entire liver. With the recipient’s weight of 57 kg, the graft to recipient weight ratio (GRWR) was 1.6%. The liver had classic hilar anatomy except that the right posterior intrahepatic duct seperately joined to the left main hepatic duct. After isolation and clamping of right hepatic artery and portal vein, indocyanine green of 2.5 mg was injected intravenously.

Results: The total operation time was 370 min and the estimated blood loss was 150 mL without transfusion. Indocyanine green fluorescence image clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. His postoperative course was uneventful and discharged postoperative day 7.

Conclusion: Real-time indocyanine green fluorescence image may be particularly helpful to delineate anatomical surgical plane and to determine the appropriate division point of hepatic duct during laparoscopic living donor hepatectomy.



F. Ratti 1, R. Reineke2, F.C. Cipriani1, G.F. Fiorentini1, A.L. Aldrighetti1 1Hepatobiliary Surgery Division, San Raffaele Hospital, MILANO, Italy; 2Anaesthesiology and Intensive care, San Raffaele Hospital, MILANO, Italy

The correct management of intraoperative volemic status is essential in laparoscopic liver resection in order to control bleeding and to perform even complex procedures with a good profile of safety. Central venous pressure is not really reliable in laparoscopy, due to presence of the pneumoperitoneum and patient position. Monitoring of haemodynamic parameters via Vigileo system is a minimally invasive method to control stroke volume variation, cardiac output, cardiac index and oxygen delivery in order to optimize the anaesthesiological management by controlling venous bleeding and avoiding tissutal ischemia.



A.F. Aranzana Gómez, J. Malo Corral, J. Hernandez Gutierrez, R. Lopez Pardo, P. Toral Guinea, A. Trinidad Borras, B. Muñoz Jimenez, A. Muñoz Tébar, G. Krasniki, M.A. Morlan Lopez General Surgery, Complejo Hospitalario Toledo, TOLEDO, Spain

Introduction: Non-hydatid liver cysts represent a heterogeneous group of disorders that differ in their etiology, prevalence and clinical manifestations.Within them, the simple hepatic cyst is the most frequent.The majority of simple cysts are an incidental finding during the performance of an imaging test for another unrelated cause and few of them are symptomatic or are associated with complications, and surgery is not necessary in most of them. described various therapeutic approaches so far there is no consensus about the optimal treatment of simple symptomatic, complicated or growth-showing liver cysts during its follow-up. Currently the laparoscopic approach is widely used for the management of cysts hepatic, with results similar to open surgery but with the advantages of laparoscopy.

Objectives: To demonstrate the safety and efficacy of the laparoscopic approach in the approximation of complicated simple hepatic cysts.Material and method: Clinical case: A 68-year-old female patient with a history of: giant hiatus hernia intervention with laparoscopic Nissen, fibromyalgia, previous ischemic colitis. Hospital admission due to pneumonia and right pleural effusion with US: SIMPLE CYST 64 X90 X99 mm in segment V HEPATIC, with dilatation of biliary radicals adjacent to the cyst, distended gallbladder with irregular walls in the hepatic side. CT: cystic lesion in segment IV–V of the liver, which has increased in size, with small microabcesses adjacencies to the lesion, thickening of the gallbladder wall, to assess cholecystitis. Antibiotic treatment is established with good evolution, deciding surgery.

Results: Intervention: complete laparoscopic approach, 4 trocars, edematous cholecystitis, large retroyuxta vesicular cyst,with thickened walls with serous content. Cholecystectomy maintaining the cyst wall, puncturing and taking samples for cytology and biochemistry of the contents, resection of the cyst wall, partial flare of its internal surface, negative intraoperative biopsy, epipoplasty, with drainage placement.Correct postoperative course.Pathological anatomy: simple biliary cyst with negative cytology, CK7+, CK20−, Calretina−.

Conclusion: the treatment of choice of complicated simple hepatic cysts is laparoscopic.We recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature,we propose cyst enucleation as the best surgical treatment.



A.L. Vargas Ávila, A.F. Palacio Vélez, G. Diazteran Aguilera, S.J. Salgado Arzate, J. Garcia Cansino, V.G. Reyes Garcia, K.B. Molina Tavarez, J. Vargas Flores, J.F. Nagore Ancona, J.M. Hernandez Garrido, C.A. Cortazar Sanchez, N.N. Espinosa Queb, L.A. Guerrero Galindo, A. Jimenez Leyva, J. Sanchez Lora, J.A. Dominguez Rodriguez, J.A. Gonzalez Luna General Surgery, ISSSTE, CIUDAD DE MEXICO, Mexico

Introduction: Polycystic liver disease (PLD) is the result of embryonic ductal plate malformation of the intrahepatic biliary tree. And usually remain silent during life. The symptoms associated with Polycystic liver disease include abdominal pain, abdominal distension and atypical symptoms because of voluminous cysts resulting in compression of adjacent tissue.

Objective: The objective of the following case is to present a patient with symptomatic polycystic liver disease, which was solved by laparoscopy approach and the management of its complications.

Material and Methods: The case reported is about a 62 years old female patient with abdominal pain in upper right quadrant associated to asthenia, adynamia and hyporexia. CT scan reported heterogeneous liver with multiple ovoid images with regular edges defined which the biggest one measure 102x99x137 mm with volume of 723 cc on segment 2 and 3, which comprises stomach, and the other one in segment 8 with a volume of 1453 cc and others small sized located in segment 6, 7 and 4B.

Results: In this laparoscopic approach, we performed a cyst unroofing of the two biggest cysts as well as cholecystectomy because of firm and lax adhesions. The patient evolved with fever in the 5th day postsurgical day and biliary leaking in a volume of 270 cc in 24 hrs. An ERCP (Endoscopic retrograde cholangiopancreatography) was asked for that was carried out by finding leak at the intrahepatic biliary duct therefore; esphinterotomy with placement of plastic endoprotesis was performed. The patient evolved without complication and was discharged at the 10th day.

Conclusions: Only symptomatic polycystic liver disease needs to be treated. The choice of treatment is not yet standardized, for voluminous cysts the unroofing ideally by laparoscopy is the gold standard and the ERCP is the elected treatment when the biliary leak appears as a complication.



J.Y. Cho, B. Lee, H.S. Han, Y.S. Yoon, Y.R. Choi Surgery, Seoul National University Bundang Hospital, SEONGNAM, Korea

Introduction: Laparoscopic liver resection (LLR) for tumors located in the posterosuperior segments of the liver (Segments (S) 7 or 8) is a challenging procedure. Especially, LLR for S7 is difficult because the access of instruments is limited, bleeding control is not feasible, major LLR is sometimes required, and obtaining sufficient resection margin is not easy. To overcome this obstacles, we performed LLR in S7 with a lateral approach using intercostal trocars. To obtain competent resection margin, LLR through right hepatic vein (RHV) first approach was performed for 1.8 cm mass located near the RHV in a 58 year old female.

Case: After full mobilization of right liver including all short hepatic veins and caudate lobe, rotate the whole liver completely to the left side to approach to the root of RHV. One intercostal trocar was inserted to access the lesion. Parenchymal transection started from the confluence of hepatic vein and then, followed along RHV with ligating several small branches from RHV. Resection margin was demarcated after localization using laparoscopic ultrasonography. After completion of parenchymal dissection using CUSA and ultrasonic shears, hemostatic agents were applied and drain was inserted.

Operation time and estimated blood loss were 120 mins and 400 ml. The patient was discharged without any complication on postoperative day 7. Final pathological assessment confirmed clear resection margin (Safety margin : 1.5 cm).

Conclusion: Laparoscopic S7 segmentectomy with hepatic vein first approach technique is safe and recommended to obtain better resection margin.



G. Rojas de la Serna, M. López Saiz, J. Riquelme Gaona, V. Crespo Garcia del Castillo, A. Morandeira Rivas, C. Moreno Sanz Digestive surgery, General Hospital, La Mancha-Centro, ALCÁZAR DE SAN JUAN, Spain

Aims: Simple liver cysts are the most common cystic lesions of the liver. Most are diagnosed casually in image tests such as ultrasound or computerized tomography, most of which are asymptomatic and do not require treatment. In symptomatic patients (abdominal distension with palpable mass, abdominal pain, dyspnea, jaundice, etc.) the clinical manifestations are usually due to the growth of the cysts or the compression of neighboring structures. Liver function tests are usually not altered. Intracystic complications occur in less than 5% of cases and malignancy is exceptional. In this video, we present the case of a symptomatic patient with polycystic liver disease including a large size hepatic cyst.

Material and Methods: 65-year-old woman with a personal history of arterial hypertension, SAOS, partial hysterectomy due to endometrial cancer, who was referred to our department complaining of supraumbilical pain and abdominal distension with palpable mases. Abdominal ultrasound showed cholelithiasis and multiple simple hepatic cysts. In CT scan, multiple hepatic cysts were found, the largest one of about 20 cm of larger diameter. Echinococcus granulosus serology test was negative. There was also no evidence of cancer disease in PET scan.

Results: A laparoscopic approach was performed with four trocars, three of 5 mm and a Hasson trocar inserted thought a umbilical small incisional hernia. Aspiration and wide unroofing of the large size cyst and smaller accessible ones was done. The patient also underwent cholecystectomy with intraoperative cholangiography and umbilical eventroplasty. The patient recovered uneventfully and is asymptomatic one year after surgery.

Conclusion: Simple liver cysts rarely require treatment. In some cases, especially in large, complicated and symptomatic simple liver cysts, surgery is indicated. Laparoscopic fenestration treatment is the best choice.



M. Alba Valmorisco1, R. Perez Quintero 2, R. Martinez Mojarro2, D. Bejarano González-Serna1, J. Candón Vázquez1, M. González Benjumea1, P. Beltrán Miranda1, R. Balongo García4 1General Surgery (Hepatobiliary surgery), Juan Ramon Jimenez Hospital, HUELVA, Spain; 2General Surgery, Juan Ramon Jimenez Hospital, HUELVA, Spain;4Genial surgery (esophagogastric surgery), Juan Ramon Jimenez Hospital, HUELVA, Spain

Aims: Liver resection is the preferable initial treatment option for solitary or limited multifocal hepatocellular carcinomas.

Surgical indications for laparoscopic liver resection (LLR) are the most important consideration, like liver function, tumor size (diameter less than 5 cm) and location (easy technical access like in the left lateral section or on the surface of the inferior region).

Partial liver resection or left lateral sectionectomy are the typical procedures for such tumors and are considered the best way to begin LLR. With accumulating experience and technical advancement, LLR has been performed for tumors larger than 5 cm and for others locations.

Some requirements to perform LLR are to have experience in liver surgery and laparoscopic also, adequate technology and Intraoperative ultrasound.

Methods: A 69-year-old male smoker, ex-parenteral drug users with chronic HCV liver disease Child-A stage. He is diagnosed with a single lesion of 7 cm in segment III of the liver, biopsied twice without conclusive diagnosis and with a three-phase CT suggestive of hepatocarcinoma LI-RADS 4 with data of portal hypertension (PHT) and mild ascites.

After the study is commented on tumor committee deciding surgical intervention.

Results: A laparoscopic resection of segment III was performed with 5 trocars. Liver is explored by intraoperative laparoscopic ultrasound. Vascular control was performed using the Pringle technique. Liver transection was done with Sonostar until identification of intraparenchymal segment III vascularization, which is sectioned with endoGIA (45 mm) with Seamguard. After the resection, we perform hemostasis control with electrocoagulation and hemostatic material. Intraoperative bleeding of 300 ml. Favorable postoperative evolution, high on the 5th postoperative day.

AP: 7 cm trabecular hepatocarcinoma moderately differentiated pT1b, R0 resection.

Conclusions: LLR allows major liver resections with low morbidity and mortality and the advantages of laparoscopic surgery. An efficient learning curve can be achieved by a parallel evolution of procedures and indications (according to modified BCLC staging system and treatment strategy). Studies suggest that LLR results in less blood loss, shorter postoperative hospital stays, lower abdominal wall trauma and lower incidences of ascites accumulation and postoperative liver failure. With respect to oncological considerations, tumor margins are adequately maintained during LLR.



V. Drakopoulos, S. Voulgaris, I. Iliadis, K. Botsakis, P. Trakosari, V. Vougas 1st Department of Surgery and Transplantation Unit, District General Hospital of Athens « Evangelismos » , ATHENS, Greece

Introduction: Laparoscopic surgery is gaining acceptance in the treatment of liver metastasis. Laparoscopic treatment of liver metastasis often presents technical difficulties and requires an extensive learning curve.

Material-Method: We present the case of a 62 year old woman presented with a liver metastasis in section 3 of the liver. The patient had been submitted to a laparoscopic low posterior resection in February 2018. Patient underwent laparoscopic left lateral hepatectomy, with the use of three trocars (umbilical 10 mm, and two in the midclavicular line bilaterally.) Left lateral hepatectomy was conducted with the use of a linear stapler. The postoperative period was uncomplicated and the patient remains in good condition three months after surgery.

Conclusion: Laparoscopic approach seems to be safe for treatment of liver metastasis, offering better surgical field view and less postoperative complications. 5 year survival rate after laparoscopic hepatectomy is compared to the open approach.



Y.Y. Liu General surgery, Chang gung memorial hospital kaohsiung division, KAOHSIUNG, Taiwan

Purpose: Laparoscopic hepatectomy is a quickly growing method for liver tumor because of modern technology. But for the IHD thrombosis, it is still technique dependent. The video was tried to share our experience for special case.

Material and method: One 68 y/o female patient suffered from fever episode and image show S56 3 cm HCC with right anterior IHD obstruction R/O tumor thrombosis, Hilum LN enlargement, double right portal vein, hilum adhesion with duodenum, no ascites . Lab data : NO-B, NO- C Child A, AFP 1199, ICG clearance rate 4.5%, PLT 174000 . Heart, lung function exam normal. The laparoscopic right total hepatectomy and hilum LN dissection was conducted.

Results: Laparoscopic approached was performed. The hilum LN dissection was done with vessel and bile duct isolation. Hilum LN frozen show negative malignancy. Hemi-vessel control was done with resecting the vessel. Right hepatectomy was done with preserving middle hepatic vein. The right anterior and posterior IHD was opened and tumor thrombosis was removed from right anterior IHD carefully. The stump of IHD was closed by suture separately. The total op time was 630 min with 345 cc blood loss. Post op minimsl bile leakage was found in the drain at day 6. The patient discharged at day 14 with drain.

Conclusions: Laparoscopic hepatectomy may be a feasible method for HCC even with IHD tumor thrombosis.



A. Pinillos, A. Escartin, M. Pablo, M.G. Marta, J.T. Jaume, J. Ortega, J. Jorge, Cirugía General, Hospital Universitario Arnau de Vilanova, LLEIDA, Spain

Introduction: The progressive laparoscopic learning in gastric surgery and the great development of instruments and laparoscopic material that facilitates the realization of advanced procedures, has led to an increase in the use of laparoscopy in the treatment of gastric cancer.

Material and methods: We present the case of a 75-year-old man without AMC with a history of ischemic heart disease who enters our surgery department for cholangitis secondary to choledocholithiasis. ERCP is requested during his admission that describes a gastric lesion from which a biopsy is taken, making it impossible to access Vater papilla to perform sphincterotomy and lithiasis extraction due to the existence of duodenal diverticula. The result of pathological anatomy of the gastric lesion was compatible with adenocarcinoma. Negative extension study. The clinical case is presented in a committee of multidisciplinary tumors and it is decided to perform surgical intervention of both pathologies.

A subtotal gastrectomy was performed with a Roux-en-Y reconstruction. Surgical time of 300 min. Choledochotomy was performed with lithiasis extraction, as well as intraoperative exploration of the bile duct and main conduits by means of a choledochoscope.

Results: Income of 9 days, with a Clavien II. The definitive pathological anatomy was an AI stage with a total of 22 isolated nodes without evidence of neoplasia in any of them, therefore it does not require adjuvant treatment. The patient is asymptomatic, with nutritional supplementation with follow-up in CCEE of Surgery.

Conclusions: In our case, there were no serious postoperative complications when performing gastric resection and bile duct exploration with drainage of the same. From the oncological point of view, the number of lymph nodes extracted and the surgical margins are similar to those obtained in patients in whom we perform open surgery; therefore, although it is a single clinical case, laparoscopy in expert surgeons is a safe and effective technique.



I. Balescu 1, A. Constantin2, C. Copaescu1 1Visceral surgery, Ponderas Academic Hospital, BUCHAREST, Romania; 2Gastroenterology, Ponderas Academic Hospital, BUCHAREST, Romania

The Puestow procedure was initially proposed to alleviate the pain in patients with chronic pancreatitis and dilated Wirsung duct. Its objective is to provide an efficient drainage of the pancreatic fluids and, in the meantime, to preserve the pancreatic tissue and minimize the risk of endocrine and exocrine pancreatic insufficiency.

Aims: to describe the particular technical aspects and the efficacy of totally laparoscopic Puestow procedure in patients with cystic duodenal dystrophy.

Methods: A 37 years old patient presenting diffuse epigastric pain, vomiting and weight loss was diagnosed at endoscopic ultrasound and biopsy with cystic duodenal dystrophy. A conservative treatment was decided with octreotide and opioids. However, due to the persistence of symptoms surgery was performed.

Results: due to the association of a dilated Wirsung duct, the patient was submitted to a Puestow procedure. The surgical procedure was completed in a minimally invasive manner; after dissecting the anterior surface of the pancreas an intraoperative ultrasound was performed in order to identify the Wirsung duct. Therefore, the pancreatic parenchyma was transected along the Wirsung duct, a totally laparoscopic pancreato-jejunostomy on Roux en Y limb being performed. The early postoperative outcome was uneventful, the patient being discharged in the sixth postoperative day. At one month and six months follow up the need for opioid treatment significantly diminished. A kinking of the enteral anastomosis required a laparoscopic intervention one year after with a very good evolution after.

Conclusions: totally laparoscopic Puestow procedure seems to be a safe and efficient method in order to treat symptomatic patients with cystic duodenal dystrophy in whom a dilated Wirsung duct is present.



T. Cipolat Mis, E. Falsetti, M.C. Cartillone, A. d’Alessandro, E. Chouillard General And Minimally Invasive Surgery, Poissy-Saint-Germain-en-Laye Medical Center, POISSY, France

Aims: The approach to the intraductal papillary mucinous neoplasm (IPMN) is various, from a radiological follow-up with magnetic resonance (RM) to the surgical treatment with a pancreatic resection [1]. The surgical approach is various and depends on the localization of the lesion and on the surgical skills[2].

Methods: A 67 years old patient was admitted at the CHI Possy-Saint Germain-en-Laye with an acute pancreatitis. At the ecoendoscopy was found a pancreatic cystic at the junction of the pancreatic body and tail with a Wirusng diameter of 5 mm. A second episode of acute pancreatitis occurred a few months later. After that episode the patient was submitted to a computer tomography (CT) that found a cystic lesion of 2 cm with an increasing dilatation of the Wirsung duct. The serum CA19-9 was 452 UI/mL. A laparoscopic SILS distal pancreatectomy with spleen conservation was performed.

Results: A trans-umbilical incision was performed with the positioning of the GelPoint SILS platform with the placement of 3 trocars. A distal pancreatectomy with a spleen preservation and without a standard linfadenectomy was performed. The pancreatic stump was closed with an Endo-GIA 60 mm with Seamguard device. Any drain was placed. The post-operative course was uneventfull. A CT scan was performed in …. post-operative day which didn’t show collections. The patient was discharged in -…… post’operative day. The histological examination shows an IPMN with low grade dysplasia. No invasive carcinomatoses cells were found.

Conclusions: The distal pancreatic SILS resection with spleen conservation is a feasible and safe technique that combine all the advantages of the minimally invasive laparoscopic approach with the esthetic advantages of the SILS approach.

[1] European evidence based guidelines on pancreatic cystic neoplasms. European Study Group on Cystic Tumours of the Pancreas. Gut. 2018 May;67(5):789-804. Epub 2018 Mar 24.



G.F. Faria, L. Freire, A.F. Cocco, A. Cabral-Correia, A.M. Gouveia Surgery, ULS Matosinhos / Hospital Pedro Hispano, MATOSINHOS, Portugal

Pancreato-duodenectomy is a complex surgery, requiring several anastomoses to reconstruct the digestive tract. Due to its technical complexity, the laparoscopic approach is not yet the gold-standard and there remains some controversy about its oncological safety. Worldwide experience is limited, and its safety and effectiveness are yet under evaluation.We present the clinical case of a 70 years-old woman with a prior history of epilepsy. She was studied due to painless obstructive jaundice and a 2 cm pancreatic head tumour was diagnosed on imaging, causing CBD and Wirsung channels’ dilatation. The tumour was considered locally resectable and she was proposed for a radical pancreato-duodenectomy.We present the main steps of the surgery including the oncological resection with lymphatic basin clearance and totally laparoscopic reconstruction.The post-operative was uneventful, and the histologic sample revealed a ductal adenocarcinoma (T2) with an R0 resection and 0/30 lymph nodes invaded. Although technically demanding, laparoscopic pancreato-duodenectomy is safe and effective requiring teams with experience both in pancreato-biliary and laparoscopic surgery.



G.F. Faria, L. Freire, A.F. Cocco, A. Cabral-Correia, A.M. Gouveia Surgery, ULS Matosinhos / Hospital Pedro Hispano, MATOSINHOS, Portugal

Chronic pancreatitis is characterized by a progressive pancreatic fibrosis with loss of endocrine and exocrine function. One of its main symptoms is debilitating pain. Surgical drainage of a dilated pancreatic duct is an option to consider in cases of refractory pain. Longitudinal pancreato-jejunostomy allows an effective decompression of the pancreatic channel and a significant improvement in the quality of life.

We present the clinical case of a 56 years-old lady with a prior history of gallstones. She was treated for an acute pancreatitis in May 2018, followed by recurrent relapses of pain and enzymatic elevation. She required opioid use for partial pain control and a significant 20 kg decrease on body weight due to ‘fear of eating’. The endo-ultrasonography and the MRI revealed a chronic pancreatitis with an 8 mm Wirsung duct with ductal stones and an atrophic body and tail.

We proposed a laparoscopic longitudinal pancreato-jejunostomy. The surgery was performed with 4 trocars, with the surgeon on the right side of the patient. We performed a trans-mesocolic 6 cm pancreato-jejunostomy. The post-operative was uneventful, and the patient was discharged on the 8th post-operative day, asymptomatic.

Laparoscopic longitudinal pancreato-jejunostomy, although effective is a technically demanding surgery but brings the benefits of a minimally invasive approach.



K. Mizunuma, Y. Ebihara Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, SAPPORO, Japan

Background: Preservation of spleen in distal pancreatectomy is also useful from the maintenance of platelets and the prevention of overwhelming post splenectomy infection. We have performed Laparoscopic Spleen Preservation Distal Pancreatectomy: LSPDP to benign and low-grade tumors of the pancreatic body tail. The aim of this study was to report our surgical experience with the method of SVP: splenic vessel preservation and WT: Warshaw technique of LSPDP, describe our techniques with videos.

Method: There are three points of our surgical technique. 1, Precede pancreatic dissection, improve the mobility of the pancreas. 2, Confirming the courses of splenic artery and classified them into two major types. 3, Preserving the left gastro-epiploic vessels and short gastric vessels.The postoperative cases of LSPDP which performed from April 2012 to September 2018 was retrospectively studied.

Result: Of 19 consecutive patients were performed LSPDP at our institute, 12 were SVP and 7 were WT. Ages, gender and BMI were similar for two groups. There were no significant differences in operative time, blood loss and length of stay after surgery. Comparing pathological finings, WT was associated with a slightly large tumor lesion (median 31 mm vs. 12.5, p = 0.08). Among the median observation period of 27 months, splenic infarction was observed in 1 case in SVP and 2 cases in WT. However, they were focal splenic infarctions, they did not need surgery or drainage. There were no cases in which late onset of splenic artery occlusion or esophageal / gastric varices.

Conculusion: After performing LSPD, the function of the spleen was good in all cases. Both SVP and WT were safe and feasible procedures.



P. Agami, R. Izrailov, A. Andrianov High Technology Surgery and Endoscopic Surgery, Moscow Clinical Scientific Center, MOSCOW, Russia

This is the case of a 61-years-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last 7 years. MSCT revealed pancreatic calcifications from 1 mm to 5-8 mm and dilatation of the main pancreatic duct in the body of the pancreas up to 4 mm. The patient underwent laparoscopic local resection of the head of the pancreas combined with longitudinal Roux-en-Y pancreaticojejunostomy—a technique known as Frey’s procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.After performing the posterior wall of the pancreaticojejunal anastomosis we’ve faced an intraoperative complication such as volvulus of the Roux limb causing serious ischemia of the limb. We were forced to remove all previous sutures in order to untwist the Roux limb, thereafter the pancreaticojejunostomy was started anew.The purpose of this video is to demonstrate that Frey’s procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. We demonstrate that even such serious intraoperative complication as volvulus of the Roux limb can be managed without conversion. Our center has an experience of over 30 laparoscopic Frey’s procedures, however this is the first case where we encountered with such complication and we believe this is an experience worth sharing.Yet we would like to underline that this approach should be used by highly skilled minimally invasive surgeons experienced in intracorporeal suturing which is the most challenging stage in Frey’s procedure.



V. Tomulescu, I. Hutopila, C. Copaescu General Surgery, Ponderas Academic Hospital, BUCHAREST, Romania

Spleen preserving Distal Pancreatectomy (SPDP) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas.

Two surgical techniques for SPDP have been described. The first technique was described by Kimura (spleen preserving distal pancreatectomy with splenic vessel preservation—SPDP-SVP) and preserves the main splenic artery and vein and excises the tail of the pancreas and those small, short vascular connections to the body;the second technique was described by Warshaw and involves resection of the splenic vein and artery before distal pancreatectomy, and conservation of theshort spleno-colic and gastric vessels to keep normal blood flow for the spleen (spleen-preserving distal pancreatectomy with splenic vessel resection—SPDP-SVR).

We present the case of a 50 years old female with 40/50 mm tumor of the pancreatic tail on ultrasonography. CT scan confirmed the tumor and endoscopic ultrasonography with FNA have shown a solid pseudopapillary tumor. Due to the low grade malignancy we have decided to perform a laparoscopic spleen preserving distal pancreatectomy with splenic vessels preservation (LSPDP-SVP). For LSPDP-SVP the difficulty is related with the splenic vessels dissection and manipulation. Primary dissection and control of main trunk of splenic artery and vein will help to quickly control bleeding during vascular rupture in small vessels dissection. Optimal stapling of any tissue requires an adequate tissue compression time to allow elongation of the tissue being compressed, smooth firing of the instrument, consistent staple line formation balanced against the risk of increased tissue tearing and excessive tensile strength. This is why, for pancreatic division, we prefer choosing a cartridge loaded with higher staplers. The pancreatic stump transection line is evaluated for bleeding and when it is needed, hemostatic clips are applied.

Histology report confirmed a Solid pseudopapillary tumor T3NoMxL0V0R0 at this moment with 12 month good follow up.

In conclusion LSPDP-SVP is safe, reproductible and demonstrated very good outcomes when certain indications are respected.



J. Tur-Martínez 1, A. Escartín1, M. González1, P. Muriel1, A. Pinillos2, J. Ortega2, J.J. Olsina1 1Hepatobiliary and Pancreatic Surgery Unit, Hospital Universitari Arnau de Vilanova, LLEIDA, Spain; 2General and Digestive Surgery Service, Hospital Universitari Arnau de Vilanova, LLEIDA, Spain

Aim: Advances in minimally invasive surgery has permitted to perform complex techniques by this approach, being the laparoscopic duodenopancreatectomy (LPD) one of these.

The aim of this communication is to present a surgical technique video for a complete laparoscopic PD, showing the most important steps of the resective and reconstructive phase, with the anastomosis realized completely by laparoscopy.

Methods: A surgical technique video is presented showing the main steps for the LPD and a complete laparoscopic reconstruction with an hepatico-jejunostomy, duct-to-mucosa pancreatic-jejunostomy and a gastro-jejunostomy.

Results: An 82 years old woman with past medial history of arteria hypertension, dyslipidemia, Type II Diabetes Mellitus and a breast cancer treated in 2009 with lumpectomy and axillary lymphadenectomy plus radiotherapy, recently diagnosed of and adenocarcinoma of the head of the pancreas. The CT scan showed a neoplasia localized in the head of the pancreas without extension to other organs. A laparoscopic PD was indicated after a multidisciplinary committee evaluation.

A supraumibical Hasson trocar was used for the pneumoperitoneum, three 12 mm trocars and two 5 mm trocars were used.

LPD was performed. The resective phase was done following the conventional steps of the open Whipple procedure and for the reconstructive phase, a Child limb was used for a termino-lateral hepatico-jejunostomy with an absorbable 4/0 monofilament; a duct-to-mucosa pancreatic-jejunostomy with an absorbable 5/0 monofilament and finally a latero-lateral mechanical gastro-jejunostomy was performed. Surgical time was 480 min. Postoperative course without complications and the patient was discharged on the 7th postoperative day.

Definitive anatomopathological exam: intraductal tubulopapilar neoplasia, 16x16x13 mm, with wide high grade epithelial dysplasia. Free margins. pTisN0 (0/12).

Conclusion: Laparoscopic PD is a feasible procedure with a high technical requirement which should be performed in specialized centres with high experience in hepatobiliary surgery and in advanced laparoscopic procedures, because of its high morbidity and mortality.



F. Antonakopoulos 1, P. Athanasopoulos1, A. Ioannidis1, M. Konstantinidis2, K. Konstantinidis1 1General Surgery, Athens Medical Center, MAROUSI, ATHENS, Greece; 2Medical School of Athens, National Kapodistrian University of Athens, ATHENS, Greece

Introduction: Pancreaticoduodenectomy—Whipple procedure remains one of the most challenging operations in general surgery. Except from the cumbersome and meticulous dissection, it requires complex reconstructive procedures with numerous anastomosis. Furthermore the presence in patients history, of previous operative interventions in the area of interest, adds a lot to the degree of difficulty in completing such cases laparoscopically.

Aim: We present our experience of 23 totally robotic Whipple pancreatoduodenectomies during the last 4 years.

Methods: All patients underwent a totally robotic Whipple procedure using the da Vinci Si robotic system. Some of the patients had history of upper GI Surgery like Billroth-II Gastrectomies, or placement of metallic CBD stents.The phases of the operation were: entrance to the omental bursa, kocherization, evaluation of the pancreatic neck and portal vein, division of pancreatic head, lymph node harvesting, ligation of the gastroduodenal artery, dissection of the stomach at the pylorus, division of proximal jejunum, division of CBD, removal of CBD stent (if present) and cholecystectomy. Reconstruction included a pancreaticogastrostomy, a choledochojejunostomy and a gastrojejunostomy. In 5 cases a pylorus preserving technique was used.

Results: There where no conversions to open. Mean operative time was 8 h. Minimal need for transfusions.In all patients that underwent Whipple, the robotic platform proved useful in dissecting adhesions from previous surgeries and in handling the CBD when stents where placed. Also proved useful in intracorporeal construction of the anastomoses. Mean ICU stay was 14 h.

Conclusions: Robotic assistance in Whipple may overcome limitations of laparoscopy and offer a minimaly invasive approach to this procedure potentially resulting in lower blood loss and less morbidity. We need further prospective randomized trials in order to determine the exact role of robotics in pancreatic surgery.



A. Lytvynenko, I. Lukecha, Yu. Khilko Laparoscopic surgery, State institution « O.Shalimov National Institute of Surgery and Transplantology » , KIEV, Ukraine

Aims: Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. The most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) is expected to be less invasive than laparoscopic distal pancreatectomy with splenectomy. However, there are few reports regarding the details of the procedure for LSPDP, and its safety remains unclear. This study aimed to evaluate the feasibility and safety of LSPDP.

Methods: Retrospective analysis of surgery treatment of 48 patients was made. LSPDP was conducted in the period from 2014 to 2017 in the department of laparoscopy surgery of State institution O.Shalimov National Institute of Surgery and Transplantology. The average age was 45 ↑1 3.4 years, the body mass index (BMI) was 28.7 ± 1.

Results: Laparoscopic distal pancreatectomys was performed in 100% of cases, were attempted in 36 female and 12 male patients. Postoperative pathological examinations revealed 17 cases of serous cystadenoma in the body and tail of the pancreas, 2 case of serous oligocystic adenoma, 20 case of mucinous cystadenoma, 3 case of neuroendocrine tumor (insulinoma), and 6 case of solid-pseudopapillary neoplasm. Complications related to the surgery were like acute pancreatitis with 3-fold increase normal plasma amylase confirmed by CT—7 cases, fluid collection—4 cases, pancreatic fistula (grade A)—3 cases. The operation time was 195.6 min, (range 157–250 min) blood loss of 50.1 g (range 0–110 g), mean hospital stay was 6.8 days (range 5–11 days). Conversion to laparotomy was in 1 case. Mortality was 0.

Conclusion: Laparoscopic spleen-preserving distal pancreatectomy is minimally invasive, safe, and feasible for the management of benign pancreatic tail tumors, with the advantages of earlier recovery and less morbidity from complications.



A.F. Aranzana Gómez1, J. Hernandez Gutierrez 1, J. Malo Corral1, B. Muñoz Jimenez1, A. Trinidad Borras1, G. Krasniki1, P. Toral Guinea1, R. Lopez Pardo1, S. Abad de Castro2, M.A. Morlan Lopez1 1General Surgery, Complejo Hospitalario Toledo, TOLEDO, Spain; 2 General Surgery, Hospital tres culturas, TOLEDO, Spain

Introduction and objectives: Cystic tumors of the pancreas are infrequent lesions (10–15%). They can present with abdominal pain, nausea or jaundice or asymptomatic with incidental diagnosis. Their diagnosis and classification can be difficult. The objective is to demonstrate the safety and efficacy of the laparoscopic approach in this pancreatic pathology.Material and methods: We present a video of the surgical intervention of a 32-year-old patient, with functional dyspepsia, with a casual diagnosis of 18-mm pancreatic LOE in the pancreas body after echo-endoscopic study and CT, suggestive of cystadenoma / mucinous cystadenocarcinoma. Prophylactic anti-pneumococcal vaccine, against Haemophilus influenzae and against Neisseria meningitidis. Spleno-caudal pancreatectomy is proposed

Results: Intervention: complete laparoscopic approach, 4 trocars. Aperutra of the splenocolic and gastrocolic ligament for access in the transcavity of the omentum. Identification of the tumor, impresses serous cystadenoma. Liberation of the superior border of the pancreas of the splenic artery. Dissection of the inferior border of the pancreas and access to the retroperitoneum, dissection of the posterior face and elevation of the neck of the pancreas identifying superior mesenteric artery and vein and 3rd duodenal portion. Identification of splenic vein and dissection of it. Individualized section of vein and splenic artery with vascular Endogia. Body and tail section with endogia 60 purple charge. Identification of Gerota fascia and left adrenal gland are respected. Liberation of the spleen of the retorperitoneum. Removing the piece in a bag. Left pleural effusion secondary to left subphrenic collection resolved with conservative management. High to 8th day. The anatomopathological result of the surgical specimen was serous cystoma, unilocular, large, free surgical border.

Conclusion: The laparoscopic approach of the cystic neoplasms of the pancreas is a valid option (if located in the body-tail of the pancreas). Applying the principles of oncological resection, the results are excellent provided that we avoid tumors of large size or with tumor invasion.



M. Alba Valmorisco1, R. Martinez Mojarro2, R. Perez Quintero 2, B. García del Pino3, J. Candón Vázquez1, D. Bejarano González-Serna1, P. Beltrán Miranda1, R. Balongo García4 1General Surgery (Hepatobiliary surgery), Juan Ramon Jimenez Hospital, HUELVA, Spain; 2General Surgery, Juan Ramon Jimenez Hospital, HUELVA, Spain; 3General Surgery (coloproctology surgery), Juan Ramon Jimenez Hospital, HUELVA, Spain; 4Genial surgery (esophagogastric surgery), Juan Ramon Jimenez Hospital, HUELVA, Spain

Aims: A pancreatic pseudocyst is an encapsulated, mature fluid collection occurring withing the pancreas that have a well-defined Wall minimal or no necrosis secondary to pancreatic injury and mediated by the enzimatic and inflammatory disruption of pancreatic tissue. It is a common complication of acute and chronic pancreatitis.

We present the case of a pancreatic pseudocyst located within the body of the pancreas due to recurrent necrotic pancreatitis.

The objective of this video is to show the minimally invasive surgical approach of this entity.

Methods: A 47-year-old man without medical history was admitted to hospital in the Digestive Service on 3 times for acute necrotizing pancreatitis. After study in which is evidenced cholelithiasis and pseudocyst in pancreatic body of 6 cm maximum diameter and formation of two peripancreatic collections without signs of superinfection, cholecystectomy is indicated.

Magnetic control cholangiography was performed after surgery and it showed an increase in the size of the pancreatic pseudocyst, suspecting Wirsung’s duct disruption. Therefore, endoscopic retrograde cholangiopancreatography (ERCP) was performed by placing a plastic pancreatic prosthesis and performing a sphincterotomy.

After hospital discharge, the patient is re-admitted due to recurrent abdominal pain without analytical alteration. TC abdominal observed an increase in the pseudocyst from 6 to 8 cm.

This case was discussed in a multidisciplinary committee and surgical intervention was decided.

Results: Laparoscopic approach is decided and four trocars were placed. Initially, a gastrostomy was performed with liquid outlet. An aspiration of the liquid and quistogastrostomy with 45 mm endoGIA was made.

The patient progresses favorably, being high on the tenth postoperative day, without complications.

Conclusions: Almost every pancreatic pseudocyst improves spontaneously and needs no specific treatment. Draining is indicated when secondary symptoms to compression, complications or rapidly enlarging are found.

Depending on the complexity of the pseudocyst, its communication with Wirsung’s duct and the existence of ductal injury, It may perform a percutaneous, endoscopic or surgical drainage.

The goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage. Only the surgical procedure is definitive.

V121—HERNIA-ADHESIONS—Abdominal wall hernia


M. Ruyssers, T. Gys, T. Lafullarde General Surgery, AZ Saint Dimpna Hospital, GEEL, Belgium

Case: A 29y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. Cardiac investigation was negative and gastroscopy showed a grade B esophagitis. He was treated medically but with only partial response. On a thoraco-abdominal CAT-scan the diagnosis of a left sided Bochdaleks’ hernia was made. The hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed.

Method: Given the clear correlation between the patients’ complaints and these anatomical findings, he was referred to our service of abdominal surgery.

We performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. The patient was tilted to his right side. Mobilization of the spleen was necessary to gain maximal access to the hernia. We were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. The defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers.

Result: Postoperatively the patient recovered well with adequate pain relief and pulmonary support. He could leave the hospital after 6 days. Control CAT-scan on day 5 postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. On follow-up 6 weeks after surgery the patient had regained normal activities and was symptom free.

Conclusion: A symptomatic left sided Bochdaleks’ hernia in adults with an ectopic intrathoracic kidney is extremely rare. We hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate.

V122—HERNIA-ADHESIONS—Abdominal wall hernia


B. Bascuas Rodrigo 1, J. Bellido Luque1, C. Dominguez Sanchez1, A. Bellido2, J. Gomez2, J.M. Suarez2, I. Sanchez-Matamoros Martin1, A. Nogales Muñoz1, F. Oliva Mompean1 1General Surgery, SAS, SEVILLA, Spain; 2General Surgery, Quiron Salud, SEVILLA, Spain

Aims: Large incisional hernias repair involves an actual problem for surgeons to face. Anterior component separation has been an important method allowing to close the fascia defects without tension while also having underlay mesh reinforcement.Therefore, we present a case of incisional hernia reparation performing endoscopic anterior component separation with advantages compared with open approach.

Method: We present the case of a 31-year-old woman, BMI 40 kg/m2, with previous laparoscopic gastric sleeve and posterior reintervention using open approach. The patient presented a 10 cm size incisional hernia M3W3. A CT scan was performed, confirming a midline incisional hernia containing colon, with an herniary defect of 11 cm. Full minimal invasive abdominal wall repair was proposed. A 2 cm size incision was made in left iliac region to reach the aponeurosis of external oblique muscle. We placed a balloon trocar and subcutaneous pneumo-dissection with 8 mmHg pressure was performed; then, we placed a 5 mm trocar in left lumbar space. The aponeurosis of external oblique muscle was incised and anterior component separation from inguinal to subcostal area was achieved. An extensive intermuscular dissection was performed to achieve complete midline closure. We performed the same procedure on the right side. Then, with laparoscopic approach using V-Loc n° 0 suture, we completely closed the midline. Eventually, we placed a 30x15 cm PTFE-c mesh fixed with a double crown of tackers and fibrin glue.

Results: Postoperatory course was uneventful and the patient was discharged 24 h after surgery without any remarkable event during his postoperative stay. The patient has been followed up for 12 months without any complication or recurrence in CT scan, confirming the correct minimally invasive reconstruction of the abdominal wall.

Conclusions: Trends in abdominal wall reconstruction and complex-hernia repairs have advanced rapidly in recent years. The goal is to perform a complete abdominal wall repair with no tension in midline incisional hernias. Endoscopic anterior component separation and laparoscopic eventroplasty with closure of the defect, leads to a complete wall reconstruction without tension and avoids drawbacks due to primary close defect in those patients with herniary defects wider than 10 cm.

V123—HERNIA-ADHESIONS—Abdominal wall hernia


F. Ferrara, F. Fiori, D. Gentile, D. Gobatti, M. Stella Department of Surgery, ASST Santi Paolo e Carlo, MILAN, Italy

Aims: Endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. To combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose Totally Endoscopic Sublay Anterior Repair (TESAR), a safe and feasible approach for the treatment of ventral and incisional midline hernias.

Methods: From May to September 2018 12 patients were referred to our Unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for TESAR. Exclusion criteria were: complicated ventral or incisional hernia (i.e. incarcerated hernia), maximum defect width > 5 cm, contraindications to general anesthesia. The procedure consisted of suprapubic access with 3 trocars, complete endoscopic pre-aponeurotic dissection, isolation and reduction of the hernial sac, bilateral incision of the medial rims of recti aponeurosis and dissection of retromuscular plane to create the retromuscular space, sublay non-absorbable mesh positioning and anterior aponeurosis reconstruction. One drain was always placed in the retromuscular space and one drain in the subcutaneous space.

Results: All procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. No intraoperative complications were registered. Total mean operative time was 148 ± 18.5 min. No post-operative major complications were registered. Only one subcutaneous seroma was registered (8.3%), and treated conservatively. The mean post-operative stay was 3.6 ± 0.6 days. At post-discharge clinical checkups drains were checked and removed when indicated. No wound complications nor recurrence were registered to date. Cosmetic and functional results were successful in all patients.

Conclusions: TESAR is a safe and feasible technique for the extra-peritoneal sublay repair of ventral hernias with totally endoscopic approach. It provides accurate hernia repair with good outcomes in terms of resolution of symptoms and post-operative complications.

V124—HERNIA-ADHESIONS—Abdominal wall hernia


R. Mizuno, M. Kondo Surgery, Kobe City Medical Center General Hospital, KOBE CITY, Japan

Backgrounds: Abdominal incisional hernia is found in more than 10% after abdominal surgery, and risk factors such as wound infection, obesity, elderly, high abdominal pressure are pointed out. Laparoscopic hernia repair using intraperitoneal onlay mesh (standard IPOM) is becoming widespread in Japan since the insurance release in 2012, and our hospital is actively working on it. Recently, IPOM plus procedure which also carries out fascia suture in addition to laparoscopic mesh placement has been introduced.

Aims: We report the clinical results of laparoscopic abdominal incisional hernia repair in our hospital.

Methods: We performed hernia repairs using a mesh for 36 cases from January 2014 to September 2018. Of these, 21 cases were standard IPOM and 15 cases were IPOM plus. There was no significant difference in the patient background such as gender, age, BMI, etc, and in the intraoperative findings such as hernia orifice diameters and adhesions. Surgical time, postoperative hospital stay, and the rate of complications such as seroma, mesh bulging, postoperative pain, hernia recurrence were compared and examined between the two groups.

Results: As a result, in IPOM plus group, the operation time was longer and the incidence rate of postoperative pain was higher, but the incidence of mesh bulging was significantly lower. Also, in some cases since 2018, the ‘ U reverse stitch method ‘ is used as an ingenuity of fascia suture in IPOM plus.

Conclusions: Laparoscopic abdominal incisional hernia repair has the advantage of being able to reliably confirm the hernia orifice from the intraperitoneal side?it is excellent in the identification of the fragile part of the abdominal wall and in the visibility of the restoration range. With regard to the IPOM plus procedure which has been introduced in the last few years, although the operation time is extended, it has usefulness such as reduction of mesh bulging. From the viewpoint of cosmetic surgery, usage of IPOM plus will increase in the future.

V125—HERNIA-ADHESIONS—Abdominal wall hernia


S.H. Kang, S.H. Ahn, D.J. Park, H.H. Kim Department of Surgery, Seoul National University Bundang Hospital, 13620, Korea

Introduction: Incisional hernia is one of the most common complications after abdominal surgery. Several methods have been introduced, and yet, there is no consensus on the best method of repair. We present a novel method for hernia repair which uses the retromuscular sublay mesh repair through a single incision at the pubic area to improve cosmesis.

Methods: Medical records of patients who underwent single-port retrorectal incisional hernia repair from May 2018 to December 2018 were reviewed. Patients were placed in supine position and a 3 cm incision was made in the pubic area below the panty line. A flap is made upwards until the defect is found and bilateral rectus sheathes are dissected. A mesh is then placed between the posterior rectus sheath and the muscle.

Results: A total of 30 patients with midline incisional hernia underwent single-port retro-rectal incisional hernia repair. Mean age was 59.0 ± 12.5 years with an average BMI of 23.4 ± 2.7. All the patients had midline hernia defect with an average of 3.4 ± 2.2 cm. Mean operation time was 59.6 ± 30.1 min and estimate blood loss was 32.6 ± 36.5 mL. There was no postoperative complication, and 27 (90%) patients were discharged on the day of surgery.

Conclusion: The single-port retrorectal incisional hernia repair is safe and effective while providing good cosmesis to selected patients with incisional hernia.

V126—HERNIA-ADHESIONS—Abdominal wall hernia


M.V. Sosa 1, M.P. Fernández2, A. Senent3, I. Alarcón4, L. Tallón3, J. Tinoco3, F.J. Padillo3, S. Morales-Conde4 1Servicio de Cirugía General y Digestiva, Hospital Universitario de Cabueñes, GIJÓN, Spain; 2Servicio de Cirugía General y Digestiva, Hospital Álvaro Junqueiro, VIGO, Spain; 3Servicio de Cirugía General y Digestiva, Hospital Universitario Virgen del Rocío, SEVILLA, Spain; 4Unidad de Innovación en Cirugia Mínimamente Invasiva. Servicio de Cirugía Genera, Hospital Universitario Virgen del Rocío, SEVILLA, Spain

Aims: Closing hernia defect during laparoscopic hernia repair is a vast extended technique nowadays. However, this technique is associated with mesh placemnt intraabdominally in contact by the abdominal content. Nowadays there is a trend to recontruct the midline and to avoid a mesh intraabdominally in those cases suitable for it, as a new step forward of minimally invasive abdominal wall reconstruction. Laparoscopic sublay approach with retromuscular placement of a mesh without mechanical fixation after reconstruction the linea alba migth be considered an option in primary hernias of the midline.

Methods: We present a case of a 47 year old male with an umbilcal hernia of 4 centimeter in diameter associated with rectus diastasis. A laparoscopic approach was performed, using one 12 and two 5 millimeter trocars placed on the left flank. The first step was to open the lateral side of the posterior fascia of the left rectus muscles, dissecting the retromuscular plane until we reach the linea alba getting into the preperitoneal space where the sac was diseected preserving the integrity of the peritoneum. The contralateral posterior fascia was also dissected all the way to the semilunaris line. The midline was closed, including th hernia defect, using a running double loop suture (Maxon-loop®). A self gripping mesh (Progrip®) is placed in the retromuscular space in a sublay position (21 cm long, 9 cm wide). Last, we close the fascia of the left rectus muscle using a barbed suture (V-Loc®).

Results: Surgical time was 80 min, being discharged of the hospital on postoperative day 1. Pain was controlled with conventional analgesia and no postoperative complications, nor seroma was detected.

Conclusions: Sublay approach for ventral hernia can provide a midline reconstruction, reestablishing abdominal function and avoiding the use of intraabdominal meshes and traumatic fixation, decreasing postoperative complications and pain.

V127—HERNIA-ADHESIONS—Abdominal wall hernia


J. Gómez Menchero 1, A. Gila Bohórquez1, J.M. Suarez Grau1, J. Garcia Moreno1, E. Licardie Bolaños2, J. Ferrufino Escobar1, J. Bellido Luque3, I. Alarcon del Agua4, S. Morales Conde4 1General Surgery, Hospital de Riotinto, MINAS DE RIOTINTO, Spain; 2Surgery, Hospital Quiron Sagrado Corazon, SEVILLA, Spain; 3Surgery, Hospital Virgen Macarena, SEVILLA, Spain; 4Surgery, Hospital Virgen del Rocio, SEVILLA, Spain

Aims: Lumbar hernia is one of the rare cases that most surgeons are not exposed to. Hence the diagnosis can be easily missed. This is often related to previous surgery as lumbotomies or primary in the superior lumbar triangle. This leads to delay in the treatment causing increased morbidity. We report a case of adquired lumbar hernia in a middle-aged woman repaired by laparoscopic approach.

Methods: A 60 years old woman with surgical history of a myelomeningocele surgery by posterior approach over 40 years ago, a laparoscopic left nephrectomy 2 years ago with a left colostomy due to a left colon injury during this procedure. A Hartmann reversal by laparoscopic approach 6 months later. Patient showed a large lumbar mass over 6 cms in the left lumbar region and a large scar near to spinal cord. It was soft in consistency, reducible and expansible on coughing and straining with defined borders. Computerized Tomography showed a large defect in the superior lumbar fascia over 6 cms in the Grynfeltt-Lesshaft triangle with the left colon inside.

Results: Patient was placed in a full lateral decubitus position. In order to optimize exposure, a lumbar roll was placed under the lumbar region. A capnoperitoneum (12–15 mmHg) was built up. One 11 mm and two 5 mm trocars were used and positioned in the left mid axillary line. A 30 optic was used. Adhesions were removed and Toldt fascia was opened in order to expose the hernia defect bounded by quadrates lumborum, erector spinae muscles, 12 rib and serratus. Hernia content was carefully extracted from the sac using a Ligasure Maryland (Covidien Medtronic-USA). Hernia defect was measured and an intraperitoneal mesh (Dinamesh-IPOM FEG Textiltechnik mbH, Aachen, Germany) was positioned and sutured by tackers to the margins included the bone.

Patient was discharged in 48 h with a low pain rate and without complications.

There is not recurrence in 10 months follow-up.

Conclusion: Laparoscopy might be a safe and feasible approach for repairing lumbar hernias, either primary or adquired, with a low rate of pain and complications

V128—HERNIA-ADHESIONS—Abdominal wall hernia


A. Senent-Boza 1, I. Alarcón1, P. García-Muñoz1, N. García-Fernández1, J. Tinoco2, L. Tallón2, F.J. Padillo2, S. Morales-Conde1 1Innovation in Minimally Invasive Surgery Unit. General and Digestive Surgery Ser, University Hospital Virgen del Rocio, SEVILLE, Spain; 2General and Digestive Surgery Service, University Hospital Virgen del Rocio, SEVILLE, Spain

Aim: Laparoscopic posterior component separation with transversus abdominis release (TAR) allows an anatomo-functional reconstruction of complex abdominal wall defects with lower complication rates than open approach. However, it is a high technical level procedure. We present a modification of the technique to simplify it.

Methods: A 62-year-old woman with a BMI of 36.73 kg/m2, with a previous umbilical hernioplasty and three eventroplasties for recurrence of the same, presents with a new symptomatic recurrence with a M2-3W2 defect showed by CT.

After pneumoperitoneum is done, three 5 mm trocars are placed on the left flank. The defect is delimited by drawing it over the skin of the patient with aid of an intramuscular needle and intraabdominal vision. Posterior fascia is opened longitudinally at its medial edge and the retromuscular space is dissected. The arcuate line of Douglas and the epigastric vessels are identified. From this point, transversus abdominis fascia is sectioned cranially 1 cm medial to the semilunar line, preserving the neuro-vascular pedicles that reach the rectus abdominis laterally.

At supraumbilical level, transversus abdominis fibers advance behind rectus abdominis, so they need to be sectioned to access to the space below the ribs. Lateral dissection of this space enables a tension-free closure at midline.

Once the procedure is repeated on the contralateral side using two 5 mm and one 12 mm trocars on the right flank, a continuous suture of the posterior fascia is performed with a barbed suture. The anterior fascia is closed with a slowly-absorbable monofilament loop-type suture.

Finally, a double-layer polypropylene mesh is placed at retromuscular level without any suture and fibrin glue is applied.

Results: The patient was discharged 24 hous after surgery. No recurrence has been presented to the moment.

Conclusions: The section of the aponeurotic plane from the arcuate line of Douglas enables a more accurate dissection of the retrotransversus plane without sectioning its fibers except for its cranial end, preserving the innervation and vascularization of the abdominal wall.

This technical modification aims to simplify a complex laparoscopic procedure allowing its estandarization.

V129—HERNIA-ADHESIONS—Abdominal wall hernia


F. del Castillo Diez 1, C. Durán Escribano2, L. García-Sancho Téllez3, J.A. Gonzalez Sanchez1, J. Díaz Dominguez1 1General Surgery, Hospital Universitario La Paz, MADRID, Spain; 2General Surgery, Hospìtal Quirón La Luz, MADRID, Spain; 3General Surgery, Hospital Universitario Infanta Sofia, MADRID, Spain

Aims: The authors present a video with their standardized laparoscopic ventral hernia intraperitoneal mesh (IPOM) hernioplasty procedure but introducing a novel laparoscopic technique for tension releasing while hernia gap closure and midline anatomical restoration.

Methods: A 64 years old male patient with a BMI 31 presents a symptomatic ventral hernia recurrence after a sigma colic cancer open surgery. A CT scan study showed a 5 cm transverse diameter midline ventral hernia. A Laparoscopic IPOM hernia repair procedure is performed using 5 mm instruments and a 10 mm camera. When checking tension while midline restoration suturing, we decide to add a tension-releasing maneuver: A totally laparoscopic transverse abdomini muscle release (TALTAR). This maneuver allow right rectus posterior sheath to advance some distance to the midline, in order to provide a tension-free midline closure. A double-faced ready-to visceral contact mesh is now placed and fixed. Case and technical details are shown in the video.

Results: The patient was discharged from hospital within a period of 5 h with a 4 rate in a EVA acute pain visual scale. In a 2 year follow-up, there has no been an anatomical or clinical recurrence. No chronic pain, anatomical recurrence, lateral asymmetry, umbilical or abdominal wall complications have been reported with this technique.

Conclusions: Depending on the patient characteristics, anatomical hernia factors and surgeon mini invasive experience, a TALTAR maneuver could be a safe and feasible option for releasing tension when midline anatomical laparoscopic closure. More studies are needed in order to standardized this approach.

V130—HERNIA-ADHESIONS—Abdominal wall hernia


G.P. Protti, R. Villalobos, Y. Maestre, M.C. Mias, A. Escartin, J.J. Olsina General Surgery, Arnau de Vilanova Hospital, LLEIDA, Spain

Aims: To present the case of a multioperated patient with 3 simultaneous hernias, that we managed to repair laparoscopically

Methods: A 45 year old male with a 29.4 BMI, hypertension and several past surgeries (Miles procedure, distal pancreatectomy with splenectomy and 2 hepatic tumorectomies), arrived at our out-patient clinic with 3 simultaneous hernias. The patient had a M2W1 incisional hernia, a type IV parastomal hernia and a perineal hernia. After discussing the different alternatives with the patient, a laparoscopic approach was selected, even though he had a complex surgical history.Under general anesthesia and with the help of three trocars, we first repaired the parastomal hernia, liberating its adhesions and reducing its contents. We placed an intraperitoneal 15 cm x 20 cm composite mesh (Dynamesh) with the key-hole technique, fixed with absorbable tackers. We then proceeded to repair the midline incisional hernia with another intraperitoneal 20 cm x 30 cm Dynamesh, fixed with absorbable tackers. This second mesh was simultaneously placed on the colostomy, on top of the previous mesh, in a Sugarbaker manner, completing the doble mesh parastomal repair technique. Lastly, we repaired the perineal hernia, using a third 15 cm x 20 cm intraperitoneal Dynamesh, fixed with both absorbable tackers to the abdominal wall and Cooper ligaments and absorbable sutures to the peritoneum surrounding the iliac vessels. No intraoperative complications occurred.The patient had an uneventful postoperative recuperation, except for a postoperative ileus which resolved with medical treatment. He left the hospital after 12 days.

Results: 1 year after the surgery, he’s had no clinical or radiological evidence of recurrence. He remains asymptomatic.

Conclusions: Patients with complex surgical histories can sometimes be operated laparoscopicaly.The simultaneous repair of multiple abdominal wall hernias or even perineal hernias is feasable and should be performed whenever possible.

V131—HERNIA-ADHESIONS—Abdominal wall hernia


J. Bellido Luque 1, B. Bascuas Rodrigo1, A. Bellido2, J. Gomez2, J.M. Suarez2, I. Sanchez-Matamoros Martin1, A. Nogales Muñoz1, F. Oliva Mompean1 1General Surgery, SAS, SEVILLA, Spain; 2General Surgery, Quiron Salud, SEVILLA, Spain

Aims: When primary ventral hernia and simultaneous diastasis recti are diagnosed, there is no consensus among the international surgical community on the surgical treatment regarding indications or surgical technique. However, if diastasis recti is symptomatic of or is associated with midline hernias, the corrective surgery of both pathologies at the same time could be the most recommended option. When we only correct the herniary defect, we risk performing a reparation on an anatomically weak tissue, so the rate of hernia recurrence may increase. We propose a minimally invasive access using totally endoscopic retromuscular hernioplasty. By developing this technique, several advantages are provided, such as no peritoneal opening without intraabdominal access, no mesh fixation needed and simultaneous solving of both pathologies.

Method: We present the case of a 50-year-old man, with BMI 35 kg/m2 and no previous medical history complaining of ventral hernia with associated recti diastasis. A 4 cm size umbilical hernia was diagnosed with a 5 cm size supraumbilical diastasis recti associated. Full endoscopy retromuscular hernioplasty was proposed. A 2 cm size incision was made in left hypocondrium, openned the anterior rectus sheath and retracted the rectus muscle. We placed a balloon trocar and open the homolateral retromuscular space after placing two 5 mm trocars in left lumbar space and epigastric position. We crossed-over the linea alba and achieve contralateral retromuscular space. After this step, the hernia sac was reduced and we extended the dissection 5 cm caudal to the hernia ring. Both medial posterior rectus sheaths were sutured with running barbed suture n° 0 and a 20x20 cm size light-weight, big pore, polipropilene mesh was placed in retromuscular space and unrolled properly with enough overlap. A drain was placed and the anterior rectus sheath incision was closed.

Results: The patient was discharged 24 h after surgery without remarkable events during his postoperative stay. He has been followed up for 8 months remaining asymptomatic.

Conclusions: Totally endoscopic retromuscular ventral hernia repair in men with umbilical hernia and diastasis recti associated, is feasible and reproducible procedure with several advantages compared to traditional laparoscopic IPOM in terms of pain and mesh position.

V132—HERNIA-ADHESIONS—Abdominal wall hernia


B. Bascuas Rodrigo1, J. Bellido Luque 1, C. Dominguez Sanchez1, A. Bellido2, J. Gomez2, J.M. Suarez2, I. Sanchez-Matamoros Martin1, A. Nogales Muñoz1, F. Oliva Mompean1 1General Surgery, SAS, SEVILLA, Spain; 2General Surgery, Quiron Salud, SEVILLA, Spain

Aims: Parastomal hernia (PH) is one of the most frequent long-term complications of stoma formation, occurring in 35%-50% of patients. Surgical treatment for parastomal hernia is the only cure but a fairly difficult field with a recurrence rate ranging from 24% to 54% of cases. Due to its advantages, the number of laparoscopic mesh repairs for parastomal hernia has gradually increased over the past decade. According to this common complication, we report a case of laparoscopic reparation of PH using the Sugarbaker technique.

Method: We present the case of a 65-year-old patient with surgical antecedent of laparoscopic low anterior resection due to rectal cancer, presenting in postoperative period an anastomosis leakage with severe peritonitis was identified and a laparotomy with end colostomy was performed. The postoperative course was uneventful. During the follow-up the patient showed a 6 centimetres size paraestomal hernia, being a M3W2 incisional hernia confirmed with CT scan.The patient underwent full laparoscopic hernia repair, performing a Sugarbaker technique, exposing parastomal hernia completely to measure the hernia ring size (6 centimetres) and the midline associated defect (5 centimetres). A 26x36 cm size PTFE-c was selected to allow a 5-cm overlap over two defects.

Results: Using this approach, the bowel loop was pushed into the abdominal wall and appropriate place between the mesh edge and the abdominal wall is left to allow the bowel loop to pass through. Postoperatory course was uneventful and the patient was discharged 48 h after surgery without any remarkable event during his postoperative stay. He has been followed up for 18 months without realizing any clinical signs or alterations in CT scan.

Conclusions: Compared with traditional open surgical repairs, laparoscopic repair has certain advantages including its safe operation, postoperative rapid recovery, fewer complications, and lower recurrence rate. However, it still faces challenges regarding parastomal hernia treatment, and there is a need to improve existing surgical techniques.

V133—HERNIA-ADHESIONS—Abdominal wall hernia


J. Bellido Luque, B. Bascuas Rodrigo, C. Dominguez Sanchez, I. Sanchez-Matamoros Martin, A. Nogales Muñoz, F. Oliva Mompean General Surgery, SAS, SEVILLA, Spain

Aims: Nowadays, the principal disadvantages of laparoscopic approach in hernia repair are the use of intraabdominal meshes and traumatic fixation. First, intraabdominal meshes involve the contact of the prosthesis with the intestinal loops with the consequent risk of adhesion and fistula. Also, using helicoidal sutures in prosthetic fixation produces adhesions to the tackers and a non-negligible incidence of chronic pain. When it comes to lead to better results, placing the mesh in retromuscular space avoids the drawback of contact with the loops, and using self-fixation meshes may decrease the rate of acute and chronic pain. Accordind to this facts, we present a case of laparoscopic ventral hernia repair with transabdominal retromuscular mesh placement without traumatic fixation.

Methods: We present a 50-year-old patient with a 7 cm diameter hernia showed in preoperative CT scan, M3W2, with diastasis recti associated. The patient underwent laparoscopic surgery using transabdominal retromuscular route. One 11 mm and two 5 mm trocar were placed in left flank. The posterior rectus sheath on the left side is opened starting 5 cms far from the left egde of the defect. Once the retromuscular space is dissected, the hernia ring is dissected and the hernia sac reduced, we continue with the dissection in retromuscular space on the side. Craniocaudal dissection is achieved 5 cm distal to the defect margins. The hernia defect with the anterior rectus sheath and the diastasis recti were closed using v-loc running suture. Self-adhesive mesh was subsequently placed. The mesh should be overlap 5 cm from the margins of the defect, covering the defect widely, with grips facing upwards. Finally, we closed the posterior rectus sheath with peritoneum on the left side with v-loc running suture.

Results: The postoperative course was uneventful and the patient was discharged 24 h after the surgery. After 18 months of follow-up no clinical or radiological recurrence was showed.

Conclusions: The combination of laparoscopic approach, retromuscular mesh placement and the use of self-fixation meshes, seems to be an actual useful solution, combining the advantages of each item and avoiding the use of intraabdominal meshes and helicoidal sutures.

V134—HERNIA-ADHESIONS—Abdominal wall hernia


F. Pulighe 1, M. Podda1, D. Delogu2, F. Balestra1, M. Anania1, M. Pazzona1, A. Cruccu1, G.P. Gusai1, M.L. Murru1, C. Massaiu1, C. de Nisco1 1General and Robotic Surgery, ATS Sardegna ASSL Nuoro, NUORO, Italy; 2General Surgery, ATS Sardegna ASSL Lanusei, LANUSEI, Italy

Aims: Laparoscopic ventral hernia repair has clear advantages over open repair, including less post-operative pain and earlier return to normal activity. However, a prolonged surgeon learning curve is necessary to perform this technique effectively. Robot assistance may improve outcomes of minimally invasive ventral hernia repair with improved three-dimensional visualization and enhanced dexterity with articulating instrumentation. We report a case of robotic Rives-Stoppa epigastric hernia repair in order to demonstrate the feasibility of the robotic approach.

Methods & Results: A 58-year-old man came to our attention for the presence of a palpable mass in the epigastric region. The abdominal CT scan showed the presence of an epigastric hernia with herniation of omental content, and the presence of diastasis recti. The patient was then submitted to a Rives-Stoppa Robotic hernia repair under general anesthesia. The da Vinci-Si Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was brought into position over the head of the patient and docked after placement of the ports. Three trocars were placed in the hypogastric region along the transtubercular line. A fourth trocar was placed in the left iliac fossa and used by the assistant. The operation started with an extended adhesiolysis and hernia reduction. Then, the retromuscolar dissection began by incising the posterior sheath starting from 4 cm above the pubic symphysis. An extended dissection of the Rives space was performed to create a correct housing for the mesh. The hernia defect and the diastasis recti were closed using a 1-0 absorbable barbed suture. A Phasix STTM mesh (Bard Inc./Davol Inc., Warwick, RI) was positioned in the retromuscular plane, and was anchored with absorbable sutures and glue. The midline incision was closed using a 2-0 absorbable barbed suture. The operative time was 250 minute. The postoperative period was uneventful, and the patient was discharged home on the second post-operative day.

Conclusions: Robotic Rives-Stoppa ventral hernia repair is feasible, safe, and effective when a standardized approach is performed. Whether robotics may improve the outcomes of minimally invasive ventral hernia repairs, including lower recurrence rates, decreased post-operative pain, or shorter surgeons’ learning curve, will require careful prospective investigation.

V135—HERNIA-ADHESIONS—Abdominal wall hernia


F. del Castillo Diez 1, L. García-Sancho Téllez2, J.D. Sanchez Lopez3, E. Ferrero Celemin3, J.A. Gonzalez Sanchez1, J. Díaz Dominguez1 1General Surgery, Hospital Universitario La Paz, MADRID, Spain; 2General Surgery, Hospital Universitario Infanta Sofia, MADRID, Spain; 3Surgery, Hospital Universitario Infanta Sofia, MADRID, Spain

Aims: The authors present a video with a left chronic Bochdaleck hernia classical hernioplasty repair but performing a mini invasive thoracoscopic approach and 3 mm instruments.

Methods: A 73 years old female patient come to hospital due to chronic left dorsolumbar pain. A CT scan study showed a chronic left diaphragmatic Bochdaleck hernia. A Lateral right decubitus thoracoscopic repair is performed using 3 mm instruments and a 5 mm camera. Case and technical details are shown in the video.

Results: The patient was discharged from hospital within a period of 48 h with no pain and a clean chest X-ray. In a 2 year time follow-up, not an anatomical or clinical recurrence has been reported. Neither chronic pain or respiratory complications happened, with in this period of time.

Conclusions: Depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, left Bochdaleck hernia mini invasive thoracoscopic hernioplasty repair using 3 mm instruments could be a safe and feasible option. More studies are needed in order to standardized this approach.

V136—HERNIA-ADHESIONS—Abdominal wall hernia


R. Villalobos, Y. Maestre, G.P. Protti, M.C. Mias, J.J. Olsina General Surgery, Arnau de Vilanova University Hospital, LLEIDA, Spain

Abdominal wall surgery has expanded exponentially in the last decade. Many techniques have been developed, mainly in minimally invasive surgery. Laparoscopic ventral and incisional hernia repair (LVIHR) has become a common procedure because of its feasibility and safety but unfortunately, it is not free of complications. Chronic postoperative pain and bleeding are frequent complications, prolonging hospital stay and altering quality of life of the patients. Absorbable or non-absorbable tacks are the usual method of mesh fixation and sometimes combined with transfascial sutures to secure the mesh. These 2 mechanical fixations pierce the abdominal wall causing nerve or vessel injuries. Some studies showed no differences between absorbable tacks, non-absorbable tacks or transfascial sutures concerning postoperative remarkably high pain. Some authors consider that a non-penetrating fixation of the mesh getting an effective mesh-abdominal wall interface will reduce significantly the postoperative pain after a laparoscopic ventral hernia repair. Tissue glues are used in different medical treatments and also have been used successfully for extra peritoneal mesh fixation in laparoscopic inguinal hernia repair, open ventral hernia repair but not so in laparoscopic ventral hernia repair in spite of good results published in the literature. Cyanoacrylate and its derivatives are ‘synthetic glues’ and classified as medical devices with stronger adherent properties than fibrin glues. Experimental studies have reported good results compared with suture fixationand also tissue toxicity doesn’t lead to an increased foreign body reaction. Some authors have studied the use of cyanoacrylate in laparoscopic inguinal hernia repair but unfortunately, clinical trial reports in ventral and incisional hernia repair were not found in the literature because the lacking of experimental studies that guarantee the safety of intra-abdominal mesh fixation and the interaction of the glue with the intra-abdominal tissue. Our group developed an experimental study demonstrating the feasibility, safety and effectiveness of the cyanoacrylate using for intraperitoneal mesh fixation and after this conclusion, started a clinical study. This video shows the methodology for laparoscopic mesh fixation with only glue in our first cases.

V137—HERNIA-ADHESIONS—Abdominal wall hernia


H. Cardoso-Louro, S. Graça, L. Lencastre, A. Fonte-Boa, J. Vilaça General Surgery, Hospital da Luz Arrábida, PORTO, Portugal

Aims: Small epigastric hernias, associated or not with the rectus abdominis diastasis, and small umbilical hernias are common in middle-aged women, particularly with past history of pregnancy. The aim of this video is to illustrate a new extraperitoneal approach to these clinical situations.

Methods: Patients between the ages of 40 and 60 years old, with epigastric hernia orifice up to 2 cm, with or without associated umbilical hernia (up to 2 cm), were chosen for this procedure.

The surgery begins with a vertical umbilical incision for the umbilical hernia’s correction, and dissection of the pre-aponeurotic plane. Two 3 mm trocars (mini-laparoscopy instruments) are introduced at both flanks to enlarge the pre-aponeurotic plane towards the xiphoid appendix. In this way epigastric hernial defects are isolated. The surgery proceeds with defect suturing with braded suture, midline invagination and mesh placement if necessary.

Results: All patients had an eventful post-operative period and were discharged home at post-operative day 1.

The aesthetic and functional results are optimal

Conclusion: For selected cases with high aesthetic motivation this technique seems to be feasible and with optimal cosmetic results. This technique allows the mesh placement both in-lay and on-lay, protecting it from surgical site infections often present at the classical approac

V138—HERNIA-ADHESIONS—Abdominal wall hernia


D. Froylich 1, F. Darawshi2, D. Levi-Faber2, R. Galili2, D. Hazzan3, R. Hadad4, E. Sharoni2 1Surgery B, Carmel Medical Center, HAIFA, Israel; 2Cardiothoracic Surgery, Carmel Medical Center, HAIFA, Israel; 3General Surgery, Carmel Medical Center, HAIFA, Israel

Aims: Bochdalek hernia is a rare entity in adults. Fewer than 200 have been reported in medical literature, the majority of which were incidentally diagnosed. As such, the optimal repair of a symptomatic hernia is unknown. We present a case of adult Bochdalek hernia repair.

Methods: A 30-year-old obese male patient with a 2 years of chronic dry cough and left lung opacity in chest x-ray. A large posterior and lateral Bochdalek hernia with herniation of intestinal loops and fat to the left hemithorax was seen in chest and upper abdominal CT scan. The hernia extended to mid-thorax, caused significant atelectasis of left lung. Eighteen months later, due to appearance of chest and abdominal pain following a recent motor vehicle accident, a repeat chest CT was done and a slight enlargement of the hernia was shown.

Results: The patient was operated laparoscopically, positioned in a semi-right lateral decubitus with double lung intubation. A large left posterior and lateral diaphragmatic hernia which contained transverse and descending colon with omental fat was seen. They were pulled in to the intraperitoneal space carefully. The defect was measured to be 10*8 cm. It was reduced to 7*7 cm by suturing with a non-absorbable 0 V-Loc suture . Advancing the camera to the thoracic cavity showed the left lung to be severely atelectatic. After selective recruitment lung was well expanded. A Symbotex Composite 20 × 25 cm mesh was fixed to the defect area by suturs and laparoscopic tacker. The operation and post-operative course were uneventful. Chest x-ray demonstrated the bowel below the diaphragm. The patient was discharged on POD 3. At 8-month follow-up, chest x-ray was normal.

Conclusion: Adult Bochdalek hernia can be safely treated laparoscopically with mesh fixation.

V139—HERNIA-ADHESIONS—Abdominal wall hernia


A.F. Aranzana Gómez, J. Malo Corral, J. Hernandez Gutierrez, B. Muñoz Jimenez, A. Muñoz Tébar, A. Trinidad Borras, J. de Pedro Conal General Surgery, Complejo Hospitalario Toledo, TOLEDO, Spain

Objective: To demonstrate the safety and efficacy of the standardized laparoscopic approach in the treatment of large parastomal hernia. Currently, this approach is recognized as the one of choice in parastomal hernia pathology, being controversial which is the best technique of choice: Keyhole vs SugarBaker.

Material and method: Clinical case: A 76-year-old woman with a history of laparoscopic abdominoperineal amputation due to rectal neoplasia (pT2N0), a year ago, with symptomatic parastomal hernia with incarceration episodes and inflamation changes in the stomal orifice.Tac: large hernia parastomal with intestinal content inside. Surgical treatment is decided.

Result Intervention: Complete laparoscopic approach, right lateral partial decubitus, 4 trocars, dissection of the hernia defect and reduction of the content, partial mobilization of the pre-stomal colon, with bleeding at the level of the vascular origin, requiring careful hemostasis to avoid ischemia of the colostomy, herniorrhaphy with stitches with extracorporeal knotting, placement of POLYPROPYLENE/PVDF mesh,fixed with irreabsorbable tackers with administration of biological glue at the edges of the mesh. Correct postoperative, discharge at the 3rd day. Asymptomatic and without hernia recurrence at one year of follow-up.

Conclusions: The technique of SugarBaker using a laparoscopic approach is a safe and effective alternative in the treatment of parstomal hernias.



J. Bellido Luque 1, I. Sanchez-Matamoros Martin1, B. Bascuas Rodrigo1, A. Tejada2, C. Dominguez Sanchez1, A. Bellido2, I. Cornejo3, F. Oliva Mompean1, A. Nogales Muñoz1 1General Surgery, SAS, SEVILLA, Spain; 2Surgery Department, Quiron Salud, SEVILLA, Spain; 3Surgery Department, Hospital Universitario Virgen Macarena, SEVILLA, Spain

Objetives: laparoscopic ventral hernia repair provides advantages in term of low infection rates and postoperatory stay when is compared with open repair. Trends in laparoscopic abdominal wall surgery is to complete defect closure without tension in midline. Closing the defect in ventral hernias wider than 8-9 cms creates high tension in midline and postoperatory pain. It’s proposed different techniques to solve this drawback. Laparoscopic posterior component separation makes the defects closure easier with no tension and placing the mesh extraperitoneally.

Methods: 65 years old woman with previous total hysterectomy, a M3M4W3 midline incisional hernia was clinically diagnosed and confirmed with CT scan. Full laparoscopic abdominal wall repair with defect closure was proposed. 3 trocars in left side were placed and posterior rectus sheath right side in the defect margin is freed. Once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. This allows access to the plane between the internal oblique and the transversus abdominis muscles. It’s is made the same steps in the left side with 3 trocar on the right flank.

The posterior rectus sheath both side is reapproximated in the midline and 20 × 20 cms Polipropilene mesh is placed and unfolded properly. It’s fixed using cyanocrilate glue.

One drain is left in retromuscular position and 10 mm trocar wounds are sutured.

Results: Postoperatory course was uneventful. Hospital stay 24 h. the drain was removed in day 3 after surgery. After 9 months follow-up no complication or recurrence were identified.

Conclusions: laparoscopic abdominal wall reconstruction with posterior component separation is an alternative to open procedure, providing no tension in midline with a complete abdominal wall repair. The mesh is placed extraperitoneally with the advantages in terms of less adhesions and postoperatory pain when is compared with traditional IPOM.

V142—HERNIA-ADHESIONS—Emergency surgery


M. Hussein Surgery, American University of Beirut Medical Center, BEIRUT, Lebanon

Aims: The role of Laparoscopic surgery for diagnosis and treatment of Acute Abdomen.

Methods: This video will show the evidence of gangrenous jejunal segment due to superior mesenteric vein thrombosis in a patient with history of breast CA on hormonal treatment.In this video, the gangrenous segment was resected and primary anastomosis was done using EndoGIA 60 mm.

Results: A second look after 48 h revealed to be negative for any further ischemic bowel.

Conclusion: Therefore, Laparoscopy in Acute abdomen is diagnostic and for treatment.

V143—HERNIA-ADHESIONS—Emergency surgery


M. Hussein Surgery, American University of Beirut Medical Center, BEIRUT, Lebanon

Aims: Laparoscopic Removal of Bezoar post Laparoscopic Roux En Y Bypass.

Methods: The incidence of Bezoar post Laparoscopic Roux En Y Bypass is increased due to wide jejunal jejunal anastomosis that results in complete intestinal obstruction.The video will show the steps used to explore the abdomen and identification of the jejunal jejunal defect and Peterson defect and the removal of the Bezoar by Enterotomy then suturing of the small intestine.

Conclusion: Laparoscopic surgery is diagnostic and theraputic in Acute Abdomen.

V144—HERNIA-ADHESIONS—Emergency surgery


A. Gila Bohórquez, J. Gómez Menchero, J.M. Suárez Grau Surgery, Hospital General De Riotinto, HUELVA, Spain

Introduction: Gastric pseudo-volvulation is a rare entity of paraesophageal hernia that is characterized by migration of the stomach into the posterior mediastinum. This clinical-radiological picture has severe complications so in certain cases should be operated urgently. Another small group of patients are asymptomatic, although the current literature recommends their regulated surgical intervention. We present a gastric pseudo-volvulation in the mediastinum, with a laparoscopic approach, showing that by systematizing the surgery, it is possible to perform this type of intervention with relative ease and safety

Material and methods: We present a video of an urgent laparoscopic approach in a female patient of 80 years with a personal history of hypertension, smoking and dyslipidemia. With a hiatus hernia diagnosed more than ten years ago. He went to the emergency department due to significant symptoms of heartburn and reflux, as well as incoerctable vomiting and difficulty feeding one week of evolution. A simple abdomen and postero-anterior chest radiograph was performed, showing a paraesophageal hiatus hernia with almost the entire stomach included in the mediastinum. A thoraco-abdominal axial tomography corroborated giant hiatus hernia with pseudovolvulation and incarceration data. Urgent intervention was decided by laparoscopic approach in which hiatus hernia reduction and esophageal abdominalization were performed. Closure of pillars and reinforcement with bioabsorbable mesh. Gastric and gastropexy Toupet of anterior face to anterior peritoneum of abdominal wall.

Results: The patient had a post-operative 48 h without incident, discharged with a crushed diet. The follow-up and evolution has been acceptable without notable complications.

Conclusion: The laparoscopic approach, in extreme cases of paraesophageal hiatus hernia with incarceration of the stomach and pseudovolvulation of it, is a correct, safe and effective alternative in experienced groups.

V145—HERNIA-ADHESIONS—Emergency surgery


P. Rymkiewicz, M. Zdrojewski General, Minimally Invasive and Elderly Surgery, Municipal Hospital, OLSZTYN, Poland

Case report of incarcerated hiatal hernia. 30 years old female was admited to the hospital due to severe chest pain and vomiting for about six h. Physical examination and lab test showed no abberations. Chest Xray revaled incarcerated stomach above the diaphragm. She was rushed to the OR. Laporoscopic approach was used, the stomach was removed from the chest and Nissen fundoplication was performed. Day after surgery patient was asymptomatic, got full oral diet. She was discharged on postoperative day two, without a need of any analgetics. Gastroduodenoscopy was performed 6 weeks after surgery and showed proper image of oesophagus, stomach and duodenum, neither signs of hiatal hernia nor inflamation were present. Laparoscopic approach is good way to treat incarcerated hiatal hernias and is related with shorter lenght of stay, lesser postoperative pain and better patient comfort. And it should be procedure of choice in this kind of cases.

V146—HERNIA-ADHESIONS—Emergency surgery


D.E. Popa 1, E. Atanasova1, A. Popa2 1Colo-rectal Division, Linköping University Hospital, LINKÖPING, Sweden; 2Gynecology Division, Linköping University Hospital, LINKÖPING, Sweden

Introduction: laparoscopic appendectomy is one of the most common operations in nowadays. But what happens when a patient, recently operated—open appendectomy, is diagnosed with a complication? Is the laparoscopic approach feasible even the prime operation was done in open manner?

Case presentation: we present the case of a 22nd years old woman who was operated for acute appendicitis. Preoperatively she had WBC: 13 and CRP:22. She was operated open technique using a 2 cm long incision in right iliac fossa and the appendix was phlegmonous. The patient began feeling bad from the second day postoperative having temperature over 38° C, pain and increasing CRP. The general condition worsened the next day when the temperature went up till 39.5° C, extreme generalized pain and CRP:343. The CT abdomen control indicates signs for generalized peritonitis and rises the suspicion for a forgotten large gauze. The patient is operated using laparoscopy technique: identifying and taking out the foreign body, doing adhesiolises, extensive lavage and in the end inserting one drain in Douglas. The video is presenting what king of special graspers can be used but also tips and tricks when speaking about identifying the anatomy but also dissection in acute and inflamed environment. Postoperatively the patient began to feel better and in the 5th day was released home.

Conclusion: this case illustrates that even after open surgery, laparoscopy is a viable solution with the condition that there is available experience in minimally invasive surgery.

V147—HERNIA-ADHESIONS—Emergency surgery


S. Alonso, A.M. Rodríguez, T. Ramos, M. Rodríguez, T. Rubio, J.E. Sánchez, M. Domínguez, E. Diego, J. López, CR. Díaz, L. Muñoz-Bellvís General Surgery, Complejo Asistencial Universitario de Salamanca, SALAMANCA, Spain

Introduction: Foreign bodies can enter inside the human body by different mechanisms such as ingestion, aspiration, trauma or in some cases due to medical procedures. They are potentially life-threatening events, the diagnosis could be challenging and its management depends on their location.

Case report: A 64-year-old male was referred to our hospital due to chronic abdominal pain. He had cholelithiasis, medical history of acute pericarditis and past surgical history of left adrenalectomy, left nephrectomy, distal pancreatectomy and colon resection due to an adrenal adenocarcinoma (stage T4N0M0).Abdominal radiograph showed a foreign body in the left lower quadrant of the abdomen, as an incidental finding. This was not detected in CT scans during ten years of oncology follow-up. CT scan revealed an extraintestinal metallic curved object in the right lower quadrant. This finding was not related to any surgical intervention or trauma. Diagnostic laparoscopy was performed: the foreign body seemed to be a guidewire, it was included into the omentum and almost stuck to the abdominal wall. The guidewire was reached and carefully extracted through a 10 mm trocar without any evidence of intra-abdominal organ injury. Then an elective cholecystectomy was also performed due to his medical history of symptomatic cholelithiasis.The procedure lasted 60 min. The hospital discharge was on the third postoperative day and no complication was registered.

Conclusion: Is extremely rare to discover a guidewire that had migrated into the peritoneal space without abdominal injuries.This case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive laparoscopic removal.

V148—HERNIA-ADHESIONS—Inguinal hernia


F. del Castillo Diez, C. Valiño Fernández, F. Atahualpa Arenas, J.T. Castell Gomez, C. Duran Escribano Surgery, Hospital Quiron La Luz, MADRID, Spain

Aims: The authors present a video with their standardized laparoscopic groin hernia transabdominal preperitoneal hernioplasty (TAP) procedure but using 3 mm instruments and 5 mm camera approach. Methods: A 45 years old male patient with a BMI 30 presents a symptomatic bilateral groin hernia for 5 months. US study showed an indirect bilateral inguinal hernia. A Laparoscopic TAP hernia repair procedure is performed using 3 mm instruments and a 5 mm camera. A self-gripping mesh preperitoneal hernioplasty and peritoneal flap barbed-sutured hermetic closure was performed. Case and technical details are shown in the video.

Results: The patient was discharged from hospital within a period of 4 h with a 2 rate in a EVA acute pain visual scale. In a 2 year follow-up, there has no been an anatomical or clinical recurrence. No chronic pain, anatomical recurrence, umbilical or abdominal wall complications have been reported with in this period of time.

Conclusions: Depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, a laparoscopic bilateral hernia repair using 3 mm instruments, could be a safe and feasible option. More studies are needed in order to standardized this approach.

V149—HERNIA-ADHESIONS—Inguinal hernia


J. Trébol 1, A.M. Rodríguez1, A.B. Sánchez-Casado1, A. García-Plaza1, J.I. González-Muñoz1, A. Carabias-Orgaz2, L. Muñoz-Bellvis1 1General and Digestive Tract Department, Complejo Asistencial Universitario de Salamanca, SALAMANCA, Spain; 2Anesthesiology, Complejo Asistencial de Zamora, ZAMORA, Spain

Aims: Post-hermiorrhaphy chronic inguinal pain is a multifactorial complex complication that needs multimodal management. For some patients, pain can be persistent and disabling. Meshes can contribute to pain by causing inflammation or entrapping nerves

Management includes conventional analgesia, nerve blocks, nerve ablation and recently nerve stimulation. Surgery includes neurectomies (selective or triple), neurolysis or simple nerve divisions usually associated with previous mesh removal and replacement with a new one.

We present a patient with refractory inguinodinia and posterior relapse managed successfully with laparoscopic previous mesh subtotal removal and TAPP, without neurectomy.

Methods: A 69 year-old male with hemochromatosis, cerebrovascular disease, hypothyroidism and eosinophilic esophagitis had bilateral Licthenstein repair one year before. This patient developed severe and impending groin pain (he needed a walking stick), diagnosed with neuralgia.

Chronic Pain Unit management ensued and 9 months later a hernia relapse occurred. Patient was offered laparoscopic TAPP repair and open groin exploration with mesh removal and eventual nerve transection.

Results: During TAPP approach a direct hernia relapse was identified, the previous mesh was included on preperitoneal space and some non-absorbable sutures to inguinal ligament were identified. Stitches and nearly total mesh removal (only the part surrounding cord elements was left in place) were performed. 15x15 heavyweight polypropylene mesh was employed fixed with Gubran2® and the flap was closed with running sutures. Patient was discharged uneventfully the same day. Seven months later he did not need analgesics and had no physical impairment.

Conclusions: Post inguinal hernia repair chronic pain can be severe and disabling, and is becoming more prevalent. The origin is complex and meshes and sutures could play a role. The management is multimodal and demanding.

For refractory patients, surgery may be an option. Laparoscopic, open and mixed approaches have been employed. They usually combine mesh removal and substitution (often in different planes) and groin nerve therapies. Nowadays, triple neurectomy seems to be the most effective treatment (more than 90% pain relief). Generally, removal of mesh alone does not lead to lasting pain relief or has worse outcomes compared with associated neurectomy.

V150—HERNIA-ADHESIONS—Inguinal hernia


J.M. Suárez Grau, J. Gómez Menchero, A. Gila Bohorquez, J.L. García Moreno, I. Duran Ferreras, P. Landra Dulato, J. Ferrufino General Surgery, Hospital Riotinto, MINAS DE RIOTINTO, Spain

Introduction: Mesh repair of inguinal hernia is sometimes followed by adverse effects such as mesh migration, chronic groin pain or recurrence. Removal of the mesh is necessary in selected cases. We affront this cases by TAPP intervention.

Methods: We present a video with two intreventions of inguinal recurrent hernia by laparoscopy (TAPP). We remar the points to decide explant the mesh or not to explant. The conditions to decide the explant were the proximity to the main vessels in inguinal area (espigastric and femoral vessels) and the plication of the mesh.

Results: and conclusion As we show in the video, the explant of the mesh is only conditioned by the plicature of the mesh for its migration and recurrence, accompanied usually with pain. We don’t remove any time the mesh or the plug if it is in the triangle of doom with firm adhesions to the main vessels. We cover the previous mesh with a new ligthweigth 3D mesh and closing at the end the preitoneum over the new reparation.

V151—HERNIA-ADHESIONS—Inguinal hernia


V. Drakopoulos, S. Voulgaris, K. Botsakis, V. Lygizos, I. Iliadis, K. Rekouna, P. Trakosari, A. Bakalis, V. Vougas 1st Department of Surgery and Transplantation Unit, District General Hospital of Athens « Evangelismos » , ATHENS, Greece

Introduction: TEP technique isn’t a controversial area in surgical practice for inguinal hernias anymore, but a fully accepted method. The use of general anesthesia has been the mainstay of laparoscopic hernia repair, but epidural anesthesia is not a contradiction to properly selected patients.

Material-Method: The approach of the extraperitoneal area achieved without use of a dilation balloon, but via the indroduction of the camera and the dissection of the regional structures.3 trocars ports were used: A 10 mm trocar through the umbilicus for the camera, exactly as in sils (single incision laparoscopic surgery), another one 5 mm is placed in the midline between the umbilicus and pubis, the last 5 mm trocar is placed in the midclavicular line ipsilateral with the hernia. The key for every operation was the tension free technique with placement and fixation of a mesh 10x5 cm. In 20/25 cases the mesh was placed with tacks on the inside of the inferior epigastric artery-vein complex. All patients were dismissed from the hospital in 24 h, no drain was placed and no major postoperative complications took place.

Conclusion: TEP is a demanding technique with serious learning curve. The use of a dilation balloon for insertion in the extraperitoneal area is not prerequisite. TEP is an appropriate method both for first appearing and recurrent inguinal hernias. Epiduralanesthesia instead of general anesthesia is no a contradiction for properly selected patients.

V152—HERNIA-ADHESIONS—Inguinal hernia


M. Zashev, A.M. Mihaylov, A. Trifunova, M. Vania, R. Gornev General Surgery, UH, Lozenetz, SOFIA, Bulgaria

Aims: The aim of this study was to investigate the effects of preperitoneal carbon-dioxide (CO2) insufflation during TAPP (transabdominal preperitoneal) repair.

Materials and methods: 20 male patients with inguinal hernia were include in our study. We obtain laparoscopic access at the umbilicus and introduce 10 mm port. Two 5 mm working ports are placed lateral. Diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. Using Aspiration Needle we insuflate carbon-dioxide (14 mmHg) preperitoneal at the level of anterior superior iliac spine while decrease abdominal gas pressure to 8 mmHg. Same procedure is made lateral to the umbilical artery.

Results: We found that preperitoneal carbon-dioxide (CO2) insufflation during TAPP facilitate the future parietalisation and even can reduce operating time in future improvements of the technique. There were no intraoperative complications related to this procedure. We did not found any potential risk of the technique when is use by trained surgeons.

Conclusion: Preperiotoneal insuflation of carbon-dioxide during TAPP is safe when special attention is paid to the key technical points and anatomical landmarks. It can facilitate the parietalisation, improve the operating time and reduce risk of peritoneal tears.

Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc. 2011;25(9):2773-843.

Lomanto D, Katara AN. Managing intra-operative complications during totally extraperitoneal repair of inguinal hernia. J Minim Access Surg. 2006;2(3):165-70.

V153—HERNIA-ADHESIONS—Inguinal hernia


J. Trébol1, I. Pascual-Migueláñez2, F. del Castillo2, S. Gortázar2, A. Carabias-Orgaz3 1General and Digestive Tract Department, Complejo Asistencial Universitario de Salamanca, SALAMANCA, Spain; 2General and Digestive Tract Surgery, Hospital Universitario La Paz, MADRID, Spain; 3Anesthesiology, Complejo Asistencial de Zamora, ZAMORA, Spain

Aims: Laparoscopic inguinal hernia repairs (LIHR) are performed more and more frequently because they offer some advantages; however, we cannot forget their specific complications. LIHR are associated sometimes with peritoneal tears that can lead to bowel obstruction.

We present two cases of bowel obstruction related to peritoneal defects post TAPP procedure and review peritoneal closure, bowel obstruction and options to repair defects.

Methods: A 79 year-old male was scheduled for TAPP due to bilateral relapse. Two 10x15 TiO2MeshTM fixed with Securestrap®, employed also for peritoneal flap closure, were employed. Three days later he was readmitted with bowel obstruction with CT suggesting ‘adhesions’.

A 56 year-old male had bilateral TAPP in another centre. Seven days later he presented with bowel obstruction. CT showed metallic tackers and suggested ‘adhesions’

Results: First case: after four days of conservative treatment failure, a revisional laparoscopy showed ileum herniation through a peritoneal defect and firm adhesions to the mesh. Bowel was labouriously separated and the peritoneal defect closed with two running sutures. He was discharged on the 7 < sup > th </sup > postoperative day and three years later he is asymptomatic.

Second: after two days of conservative treatment failure, on laparoscopy, ileum was filmy adhered to polipropilene mesh through a big defect on flap closure. Defect was closed with interrupted sutures. As tears persisted, an omental flap was created to cover the area. Patient was discharged on the 5th day and continues asymptomatic three years later.

Conclusions: LIHR bowel obstructions can be divided in adhesive disease and herniation. Herniation can be early (through peritoneal defects) or late (trocar site).

International guidelines recommends a thorough closure of peritoneal incision or bigger tears (Grade B). The closure can be achieved with staples, tacks, running suture, or glue. These last two methods are more time-consuming but less painful. Running suture seems to be the best, due to its low costs, tightness and low pain but sometimes can be technically difficult. Low intra-abdominal pressures (= 8 mmHg) facilitate suturing.

When a herniation appears, careful bowel management is needed and running sutures are recommended. If tears persist, an omental flap can be useful.



J. Marks, J. Josse, B. Anderson, H. Schoonyoung Lankenau Medical Center, WYNNEWOOD, United States of America

Aims: Application of a Single Port robotic platform to perform an entirely transanal taTME/TATA.

Methods: The following video demonstrates how a totally transanal proctosigmoidectomy is performed using a novel, Single Port (SP) robotic platform was used to carry out a totally transanal proctosigmoidectomy, Single Port robotic taTME/TATA. A 38-year-old female patient with a clinical T3N1b rectal cancer at the 3 cm level, status post neoadjuvant chemoradiotherapy (5580 cGy, Xeloda) is presented. Shown here is the open transanal dissection followed by docking of the SP robot, implementation of the single port instruments (fenestrated bipolar forceps, cadier, scissors, camera, clip applier) through a GelPoint Path to complete a totally transanal proctosigmoidectomy including transanal taTME, IMA/IMV transection, splenic flexure release, and left colonic mobilization, loop ileostomy, and handsewn coloanal anastomosis.

Results: Blood loss was 100 cc. Pathology demonstrated a moderately differentiated, rectal adenocarcinoma. The total mesorectal excision was complete (Grade 3), margins were negative, and all 17 lymph nodes were negative for metastatic carcinoma. The patient was discharged on postoperative day 4 after an uncomplicated hospital course. There was no postoperative morbidity or mortality.

Conclusions: Application of the Single Port robot to transanal taTME/TATA (SPRtaTME) is presented here. While much work remains to be done to validate the SP robot’s safety, this first demonstration of a totally transanal taTME/TATA establishes its feasibility and utility. This Single Port platform stands to greatly expand the application of natural orifice transluminal endoscopic surgery (NOTES). As shown, the SP robot offers more than sufficient visualization, technical control, and adequate reach to perform such an operation. We present an exciting new avenue by which to complete operations in an entirely transanal fashion, which are classically performed via a combined transanal and transabdominal approach.



J. Marks, J. Salem, J. Josse, B. Anderson, H. Schoonyoung Lankenau Medical Center, WYNNEWOOD, United States of America

Aims: To share the initial experience using Single Port (SP) robotic TEM (RTEM).

Methods: This video shows the utilization of a new robotic platform to perform Transanal Endoluminal Microsurgery, RTEM. Presented here is a 53 year old woman with a recurrent rectal adenoma at the 6 cm level, status post a previous TEM resection in October 2017. Demonstrated is the utilization of the SP robot through a GelPoint Path in order to perform a partial full-thickness and full-thickness resection. The robot is introduced through a 25 mm in diameter cannula via a four-channel face-plate. The instruments’ two-jointed mobility at the elbows and wrists as well as the novel navigation system are well demonstrated. The docking of the SP robot, utilization of the dissecting devices, and closure of the defect is shown.

Results: spRTEM was performed with a blood loss of 5 cc, and the patient was discharged on postoperative day 1. There was no postoperative morbidity, mortality, or moderate/severe pain. Pathology showed tubular adenoma with low-grade dysplasia in a non-fragmented specimen with negative margins circumferentially.

Conclusion: Initial Experience using the SP Robot for rTEM is demonstrated here. The robot provides wonderful visualization and operative control to the surgeon. Articulation of the robot’s wrists and arms have the potential to facilitate technical aspects of the procedure. RTEM stands as an exciting development in the field of transanal endoluminal surgery.



M.V. Marino 1, G. Gulotta2, A.L. Komorowski3 1Emergency and General Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, PALERMO, Italy; 2Emergency and General Surgery, Policlinico Universitario, Paolo Giaccone, PALERMO, Italy; 3Department of Surgical Oncology, Maria Sklodowska-Curie Memorial Institute of Oncology Cancer Centre, KRAKOW, Poland

Introduction: The application of robotic approach in the esophageal surgical field is in its first phase. The microsuturing and microdissection capabilites of the robotic system can potentially overcome the traditional limitation of the laparoscopic surgery thus enhancing the indications of minimally invasive surgery.

Methods: We have performed a retrospective analysis of our prospectively maintained database that included 16 patients who underwent robotic-assisted esophagectomy for malignant disease between 2014 and 2017.

Results: Ten out of sixteen patients had squamous cell carcinoma meanwhile six had adenocarcinoma. Ten McKeown’s and six Ivor Lewis were performed. The mean operative time was 525 min (332-688) and the median blood loss was 155 ml (70-220). No patients required conversion nor intraoperative transfusion. The morbidity rate was 3/16 (18.7%) : a transitory laryngeal nerve paresis, a pneumotorax and pneumonia. The mean hospital stay was 8 (range 7-23) days. An R0 resection rate of 93.7% was achieved with a mean lymph node yield of 16 (13-21). The 1-year disease free survival was 82.8%, wheres the the 1-year overall survival was 88.5%.

Conclusions: Robotic assisted minimally invasive esophagectomy (RAMIE) is safe and feasible, it offers promising results while preserving a good oncology adequacy.

V157—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


F. Proietti 1, M. Fitzgerald1, F. Mongelli2, M. di Giuseppe1 1Surgery, San Giovanni Hospital—EOC—Bellinzona (CH), BELLINZONA, Switzerland; 2Surgery, Luzerner Kantonsspital, LUZERN, Switzerland

This video shows our technique for the treatment of an esophageal diverticolum using a robotic left sided transthoracic approach, followed by a heller myotomy and Dor fundoplication using a transabdominal approach.

Our case is a 75 year old male, who suffered from severe dysphagia, halitosis and gastric reflux who on endoscopic and radiological investigations was found to have low grade and a 3 cm wide esophageal diverticulum, 7 cm from the Lower Esophageal Sphincter.

Initially conservative management was attempted, however following poor compliance and the persistance of symptoms after 1 year of therapy, surgical intervention was indicated.

The operation was performed using the minimally invasive robotic system of the DaVinci Si®, starting with the thorax time. The patient is positioned in left side decubitus.

The camera-trocar is insert in the thorax via the fifth intercostal space the, two 8 mm and one 12 mm robotic trocars are added.

The lung is liberated from pleural adhesions and the esophagus is then prepared exposing the diverticulum which is successfully removed with an Endo-GIA®.

The esophageal muscle fibers, near the suture line is reinforced with separated Vicryl stitches and the resected piece is extracted via Endo-bag. A 16fr thoracic drainage tube is then placed and the trocar accesses repaired.

The patient is the put in supine position with a 15° anti-trendelemburg angle. Three robotic trocars (two 8 mm and one 12 mm) are placed and the robot docking is made from the patient left shoulder.

The lesser omentum is divided to visualize and prepare the Gastric-Esophageal Junction (GEJ) sparing the vagus nerve.

The Heller myotomy is then performed for 4 cm over the GEJ and 3 cm under it. The mucosal integrity is assured via laparoscopic and contemporary gastroscopic view.

The gastric fundus is attached to the distal esophagus completing the Dor fundoplication.

Post-operative care comprehends the removal of the thoracic drainage during the first post-operative day, the pain management and the progressive realimentation.

The hospitalized period lasts 6 day and the patient was dismissed without complications occurred.

V158—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


F.A. Dobritoiu 1, D. Dobritoiu2, D. Godoroja3, S. Slaniceanu4 1Thoracic surgery, Ponderas Academic Hospital, BUCHAREST, Romania; 2Pediatric surgery, Ponderas Academic Hospital, BUCHAREST, Romania; 3Intensive care, Ponderas Academic Hospital, BUCHAREST, Romania; 4Pathology, Santomar OncoDiagnostic, CLUJ NAPOCA, Romania

The uniportal video assisted lung lobectomies gained popularity all over the world during the last 10 years. The technique is safely applied for peripheral pulmonary lesions, under 6 cm, but more and more complex cases are being approached while the indications continue to evolve.

Our aim is to present the particular aspects of this technique in an 11-year-old female patient with a giant bullous lesion located in the lower lobe of the right lung.

The preoperative work-up for this case is presented and commented. A multidisciplinary surgical team consisting of thoracic and pediatric surgeons was involved. A single 3.5 cm length incision in the fourth intercostal space was used for the access. Due to the fact that the lesion involved almost the entire lobe and the margins were very close to the hilum, we have decided and performed a right lower lobectomy. Dissection and stapling were quite difficult. All the anatomical structures had small dimensions, forcing us to perform an ‘artery first approach’ in a very narrow space. No complications during or after surgery were encountered. The patient was discharged after four days and she went to school on the sixth day. Histopathological examination showed that the lesion was a type 1 CCAM (congenital cystic adenomatoid malformation).

Conclussion: The uniportal video assisted lung lobectomy was safety applied for a giant bullous lesion of the right lung.

V159—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


N. Dowgiallo-Wnukiewicz, P. Lech, P. Rymkiewicz, M. Michalik Department of General, Minimally Invasive and Elderly Surgery, University of Warmia and Mazury in Olsztyn, OLSZTYN, Poland

Aim: Dunbar syndrome, celiac trunk (CT) compression syndrome, caused by median arcuateligament is a rarely diagnosed disease because of its nonspecific symptoms, which cause adelay in the correct diagnosis. The aim of the study was to demonstrate the usefulness andadvantages of laparoscopic approach in the treatment of Dunbar syndrome.

Methods: We performed 3 laparoscopic release of CT in the Department of General, MinimallyInvasive and Elderly Surgery in Olsztyn in 2018. All of three patients suffered from severepain of abdominal cavity before the surgery.

Results: In two cases, there were a complete remission of the symptoms. In one case, there was animprovement. All patients reported relief of symptoms in the first days after the operation.There were no postoperative complications.

Conclusions: The laparoscopic treatment of Dunbar seems to be safe and feasible procedure. Thelaparoscopic surgery alone can often eliminate discomfort, while angioplasty and stentimplantation are no longer necessary.

V160—ROBOTICS & NEW TECHNIQUES—Basic and Technical research


M. Fitzgerald < , F. Mongelli2, M. di Giuseppe1 1Surgery, San Giovanni Hospital—EOC—Bellinzona (CH), BELLINZONA, Switzerland; 2Surgery, Luzerner Kantonsspital, LUZERN, Switzerland

Introduction: The advances in robotic surgery have permitted the application of such technology to various surgical fields, one of the last of these being hernia surgery. We present a case video of the treatment of a dual-hernia using a Robotic Retromuscular Ventral Hernia Repair(rRVHR) using the DaVinci Si® robotic system.

The case report demonstrates the evolution of the Trans-abdominal Robotic Umbilical Prosthetic (TARUP) in that it utilises a ‘double docking’ technique to allow the positioning of a large retromuscular mesh.

Methodology: Our patient is a 50-year-old male who presented with chronic epigastric pain. The abdominal CT confirmed two abdominal wall hernias; an epigastric and supra-umbilical hernia with visceral contents and wall defect diameter of 6 cm and 2.5 cm, respectively.

Using the minimally invasive robotic system of the DaVinci Si® we adapted the well known retromuscular mesh technique. The operation was initially intraperitoneal with access to the retromuscular preperitoneale space using a right sided longitudinal incision.(as per standard TARUP technique).

We proceed with the dissection of the retro-muscular space until the left lateral edges of the rectus sheath, creating a preperitoneal space for the placement of a specifically modified UltraPro polyprolene® 25x22 cm mesh. Following this we repositioned the DaVinci Si® in a symmetrical manner, with ports placed in the retromuscular space. The mesh is positioned and the peritneum subsequently closed with a V-lock suture®. Finally we opted for a negative pressure Jackson-pratt drain, inserted preperitoneally.

Results: The patient was discharged on the 2nd post-operative day without complication Follow up continued until 12 months post operatively during which the patient remained asymptomatic, without signs for hernia recurrance .

Conclusion: The technique highlighted in our video demonstrates the utility of the robotic system in hernia repair. Specifically the approach proved a success as it facilites the placement of the mesh totally extra-peritoneally with closure of the posteriore sheath without tension. The added advantages are that the port-sites are distant from the mesh thus reducing infective risk. Additionally this technique allows the treatment of large peritoneal defects.



P. Tejedor, J.S. Khan, F. Sagias Colorectal Surgery, Queen Alexandra Hospital, PORTSMOUTH, United Kingdom

Aim: To analyse the performance of a robotic fellow during a robotic total mesorectal excision (TME) at the end of the fellowship, and subsequently compare it with their mentor.

Methods: The fellow is exposed to 2 robotic colorectal lists per week. During the fellowship, assessment of performance is recorded in a structured proforma covering aspects of autonomy, tissue handling and dissection.

At the end of the fellowship, areview of cases performed by the fellow and the mentor was carried out in a blindly manner (video footage).

Results: Robotic TME training was divided into modules in order of complexity and the trainee had to achieve sequential proficiency in each module, before progression.

Docking of daVinci robotic system.

Inferior mesenteric artery exposure and ligation, development of medial to lateral plane and inferior mesenteric vein division.

Left colonic and splenic flexure mobilization. Pancreas identification.

Rectal dissection (TME).

Qualitative assessments were recorded by the mentor; The fellow was ‘able to perform with verbal help’ most of the steps from early on. By the end of the fellowship, all steps were performed in a similar manner in terms of quality and oncological integrity when compared with the mentor.

Conclusions: At completion ofan advanced robotic colorectal fellowship, high quality trainees can perform every step of the TME dissection in a similar manner with the trainer, when assessed blindly, without compromising oncological integrity.



T. Kiyomatsu 1, K. Ohtani1, K. Deguchi1, Y. Gohda1, Y. Nagai1, N. Kokudo2 1Department of Colorectal Surgery, National Center for Global Health and Medicine, TOKYO, Japan; 2Department of Surgery, National Center for Global Health and Medicine, TOKYO, Japan

Aims: To find safe and simple method in robotic rectal low anterior resection with low tie arterial ligation and lymph node dissection around the root of inferior mesenteric artery.

Methods: We performed robotic rectal low anterior resection (RLAR) by daVinci Si system in eight patients with rectal cancer. We applied low tie arterial ligation, just caudally to the origin of the left colic artery in all cases. During the procedure, we used TilePro function of daVinci Si system which enabled to display two other visual informations through external inputs under the normal 3-dimensional surgeon console view. Preoperative 3D-CT vessel branching simulation video and intra-operative real time ultra sound navigation view were displayed simultaneously under normal operative camera view in the surgeon console.

Results: Left colic artery preservation was completely done in all 8 cases. The mean time to find and expose the left colic artery from the first incision in sigmoid mesentery was 5 min, which was drastically shorter than conventional method. This method needed lesser mobilization of inferior mesenteric artery (IMA), and may be less invasive to autonomic nerve around the root of IMA which is very important for ejaculation function.

Conclusion: Robotic rectal low anterior resection with low tie arterial ligation was performed safely and in short time, using TilePro intra-operative navigation method. Preoperative 3D-CT vessel branching simulation video and intra-operative real time ultra sound navigation view were very useful in the procedure. We present the method in video.



P. Tejedor, F. Sagias, J.S. Khan Colorectal Surgery, Queen Alexandra Hospital, PORTSMOUTH, United Kingdom

Aim: To describe the critical points in which the pelvic nerves can be damaged during a Total Mesorectal Excision (TME) for rectal cancer and the benefits of robotic surgery for identifying these points.

Methods: There are 4 critical points regarding pelvic neuroanatomy:

Superior hypogastric plexus (SHP): located in front of L5-S1. The ganglionic sympathetic fibres form the right and left sympathetic trunk, travel along the anterior surface of the aorta and coalesce in the SHP at the level of the inferior mesenteric artery (IMA).

Superior hypogastric nerves: they take an anterolateral course into the pelvis. There is an avascular ‘holy plane’ around the rectum between these two nerves.

Inferior hypogastric plexus (IHP): lies over the posterolateral pelvis, almost parallel to the internal iliac arteries. This can be identified at the lower end of the rectum.

Neurovascular bundles(of Walsh): in front of the Denonvillier’s fascia, at 2 and 10 o’clock position. They are responsible for erectile function.

Results: Lack of knowledge or identification of key structures at these 4 points can lead to increased risk of nerve damage and translate into poor functional outcomes.

The IMA is dissected up to the origin from aorta and here the SHP can be seen. Care is taken to avoid any damage to these structures.

The TME plane is found at the back of IMA as the inner most dissectible layer between mesorectum pelvic fascia. Right and left superior hypogastric nerves are identified. Dissection is carried out posteriorly, laterally and anteriorly.

IHP is identified at the lower third of the rectum, when the dissection is about to reach the pelvic floor. Care should be taken in not to go too far lateral and damage this plexus.

In the anterior dissection, plane is carried in front of the Denonvilliers’ fascia. The neurovascular bundles can be seen at 2 and 10 o’clock position and the surgeon has to be careful to stay inside that plane in order to avoid damage.

Conclusions: The precise dissection in robotic surgery results in minimal tissue damage and better visualization and preservation of the pelvic nerves.



S. Alonso 1, T. García2, I. Alarcón2, Y. Yang2, E. Licardie2, A. Senent2, F. López2, A. Barranco2, M. Socas2, J. Padillo2, S. Morales-Conde2 1General Surgery, Complejo Asistencial Universitario de Salamanca, SALAMANCA, Spain; 2General Surgery, Unidad de Innovación en Cirugía Mínimamente Invasiva. H. Virgen del Rocío, SEVILLA, Spain

Aims: To describe and evaluate new contributions and eventual advantages of ICG fluorescence to perform an ICG guided bilateral pelvic lymph node dissection in a patient who underwent low-anterior-resection for rectal carcinoma. We also present the basic steps to avoid ileostomy during rectal surgery in which ICG and ghost ileostomy play an important role.

Methods: A 68-year-old male patient was referred to our hospital due to abdominal pain and significant changes in usual bowel habits.Colonoscopy showed a no obstructing 5 cm middle rectal mass, which was reported as an adenocarcinoma.CT scan and MRI revealed a 63 × 52 mm polyp in the anterior rectal wall which was located 7 cm from the anal verge. It was involving mucosa and sub-mucosa with muscularis propia invasion. No pathological lymphadenopathies or hepatic metastatic disease were found (stage T2N0).A laparoscopic ultra-low-anterior resection plus ICG lateral lymphadenectomy with total mesorectal excision was performed. A complete splenic flexure mobilization was performed to achieve a safe tension-free anastomosis. Transection line of the proximal rectum was checked after ICG intravenous injection. ICG was injected around the tumor by inserting an anoscope, just before the surgery. After the dissection of the rectum, lateral lymphadenectomy was performed assisted by ICG. An end-to-side anastomosis was made. And a vascular loop was passed around the terminal ileum to create a ghost ileostomy.The procedure lasted 120 min. Reactive protein C was monitored to identify an initial leak. The patient was discharge in postoperative day 7 and no complication was detected.

Results: Pathological exam reported a rectal adenocarcinoma. Pelvic lymphadenectomy results were: 2 negative nodes, 2 negative nodes and 10 negative nodes from right lymph node dissection, left lymph node dissection and rectosigmoid resection specimen respectively. No metastatic disease was found (stage T1N0M0).

Conclusions: In our experience, ICG fluorescence imaging system offers important contributions to rectal surgery furthermore than evaluating vascular supply to the anastomosis. Lymphatic mapping of the lateral lymph nodes and avoiding ileostomy could be a potential important use in the future. Larger studies and more specific evaluations are needed to confirm its role in colorectal surgery and to find its limitations.



A.M. Otero, R. Bravo, F.B. de Lacy, A.M. Lacy Gastrointestinal Surgery, Hospital Clinic, BARCELONA, Spain

Background: Robotic surgery for colorectal cancer is an emerging technique. Potential benefits as compared to conventional laparoscopic surgery have been demonstrated. Innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery such as hand-eye coordination, a two-dimensional view, and a restricted range of motion. Robotic-assisted surgery was established as a new approach to minimally invasive surgery, overcoming these limitations.

The following video shows a total robotic sigmoidectomy step by step on the basis of ourexperience.

Intervention: A 52-year-old male patient with no previous medical historyand a colon adenocarcinoma, 22 cm from the anal verge, no distant metastases. It was decided to perform a robotic sigmoidectomy.

Target anatomywas located andwe proceededto the exposure of the mesenteric vessels from medial to lateral. A cautery wasused to open the peritoneum,up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.The vessels weretransected by LigaSureTM. We performedthe complete release of the colon taking care to avoid injury to retroperitoneal structures.

We usedLigaSureTM to section the mesocolon in order to prepare the transection of the proximal colon. Indocyanine green was used to check the correct vascularization. An EndoGIA TriStapleTM was used to divide the colon. Subsequently, we sectioned the rectumand extracted the specimen through itwith no need to make any auxiliary incisions. We introduced the anvil of the suture device to perform the anastomosis. We sectionedand close the rectum with an EndoGIA TriStapleTM.

Finally we opened the proximal colon to introduce the anvil,making a pursestring to fix it and create a side to end anastomosis.

Outcome: The surgery took 110 min. The patient started oral intake 6 h after surgery and left the hospital on the 3rd postoperative day. Pathological examination ruled out a colon adenocarcinoma pT1N0.

Conclusion: Total robotic sigmoidectomy is safe and feasible and can be a procedure of choice to achieve a good surgical qualityand avoid assistance incisions in patients with colon cancer.



M.F. Shah 1, S. Penteleimonitis1, N. Irfan Ul Islam2, N. Figueiredo3, A. Parvaiz4 1Department of surgery, Poole District Hospital Foundation Trust UK, POOLE, DORSET, United Kingdom; 2Minimally Invasive Colorectal Unit, Champalimaud Foundation, LISBON, Portugal; 3Colorectal Unit, Champalimaud Foundation, LISBOA, Portugal; 4Minimal Access and Robotic Colorectal Surgery, Poole Hospital NHS Trust, POOLE, United Kingdom

Surgery for rectal cancer has always been challenging. With the advent of neoadjuvant chemoradiotherapy for locally advance rectal cancer there have been patients having complete clinical response. With more and more data now advocating wait and watch policy for these patients which require close radiological and endoscopic follow-up but unfortunately around 30% of them have regrowth of tumour which will require surgical intervention. The use of robot for cancer resections is becoming more frequent especially in narrow spaces like in an obese male pelvis. The reason being better 3-dimensional views, more angulation of the instruments and exclusion of tremors, which in turn leads to better dissection and preservation of hypogastric nerves.

In this video, we present a robotic low anterior resection for rectal re-growth in an obese 55-years old male patient. He was offered Neoadjuvant chemoradiotherapy after discussion in MDT. He had an complete response with chemoradiotherapy and was decided to offer him watch and wait regime. Unfortunately, he developed rectal re-growth in the first year of his follow up. Imaging showed T2 lesion with no distant metastasis and was later confirmed on histology as well. After MDT discussion he was offered robotic low anterior resection.

The video starts by showing the clinicopathological features of patient including his radiological and endoscopic images. Robotic port sites are shown. The edited video starts with rectal dissection after ligation of inferior mesenteric artery and vein with emphasis on narrow pelvis and preservation of hypogastric nerves, seminal vesicles and intact presacral fascia. Postoperative histology was ypT2No and patient was discharged home after 3 days with no postoperative complications.

V167nores—ROBOTICS & NEW TECHNIQUES—Colorectal


C. Zhang, J. Li Department of Gastrointestinal Surgery, Henan People’s provincial Hospital, ZHENGZHOU, China

Background: Minimally invasive surgery for colon resection has improved patient outcome, however a minilaparotomy still is necessary to extract the specimen. This report describes a new approach that combine laparoscopic parellel overlap stapling left colectomy with natural orifice specimen extraction surgery, with the aim to minimize abdominal wall trauma.

Method: Laparoscopic left colectomy for malignant diesease was performed using a standard five-port technique. After releasing the left colon via laparoscopy, divide the proximal and distal of specimen with 60-Echelon, and put distal sigmoid colon and proximal transverse colon together. Open sigmoid colon 6 cm apart from distal margin, and incise transverse colon at proximal margin. Take transverse colon and sigmoid colon side-to-side anastomosis via 60-Echelon. Incise posterior vaginal fornix to get into the abdominal cavity and extract specimen through vaginal. Outcome parameters such as complications, conversions, operative time, postoperative recovery, and postoperative pain were prospectively recorded in a database.

Results: Surgery was performed for 17 patients with left-colonic carcinoma. No perioperative complications or conversions occurred. The median operating time was 157 min. The median visual analogue scale score of postoperative pain was 1, and 2 of 17 patients needed analgesia on postoperative day 1. The median postoperative hospital stay was 6 days. For malignancies, tissue margins were oncologically adequate, the averge number of harvested lymph nodes were 16.9. The 4-week follow-up period was uneventful.

Conclusion: The described technique, a combination of laparoscopic parellel overlap stapling and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections.



M. Abdeldayem 1, J. Waterman1, D. Brown3, P.N. Haray4 1Colorectal Surgery, Prince Charles Hospital, MERTHYR TYDFIL, United Kingdom; 3Digimed®, ESSEX, United Kingdom; 4Colorectal Surgery, University of South Wales, WALES, United Kingdom

Background: Open surgical skills training has been well established over centuries, however, there are some significant differences in laparoscopic surgical skills training. It is an obvious advantage that the trainee and the trainer have the same view; however, some of the hurdles include the differences in tactile feedback, hand eye co-ordination, spatial awareness, depth perception and maximizing assistance.

Aim: We present a video highlighting some of the key challenges faced in laparoscopic colorectal surgical training, show-casing our systematic, structured approach.

Our approach: We have developed a structured approach starting with junior surgical trainees and progressing through to consultant level as per the levels below:

Level 1: Attend courses/ workshops

Level 2: Master camera work

Level 3: Contra-lateral assisting

Level 4: Intermediate level trainee—start operating with trainer scrubbed. The trainer is an additional member of the scrub team and stands on the same side as the trainee (does not replace any assistant)

Level 5: Advanced level trainee—gradual progression from level 4. Trainer un-scrubbed but standing next to the monitor throughout the procedure.

Level 6: Trainer in theatre but out of sight of the trainee, with little interference

Level 7: Progression to Trainer—Once proficiency is achieved at level 5/6, the trainee is trained to become a trainer, for the junior and intermediate level trainees.

Within each level the complexity of the procedure increases as the trainee progresses through the level. Junior trainees (years 1–3 of surgical training) are taken through Levels 1–3, Intermediate (middle years of training) Level 4 or 5 and Advanced (last 2–3 years) up to levels 7. This way of training allows multiple members of the team to be trained simultaneously in every case. Each operating list is preceded by team briefings where the role of every member of the team is clearly identified and followed by individual and collective feedback.

Conclusion: This training ladder proved very successful through the years. The feedback from trainees at all stages has been consistently positive. Several trainees who have progressed to independent consultant practice, in the UK and abroad, are adopting this approach in their practice.



M.V. Marino 1, G. Gulotta2, A.L. Komorowski3 1Emergency and General Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, PALERMO, Italy; 2Emergency and General Surgery, Policlinico Universitario, Paolo Giaccone, PALERMO, Italy; 3Department of Surgical Oncology, Maria Sklodowska-Curie Memorial Institute of Oncology Cancer Centre, KRAKOW, Poland

Introduction: Despite the potential microsuturing capabilities of the robotic surgery, most of the esofago-jejunostomy after robotic total gastrectomy are still performed extracorporeal or through mechanical staplers. This can increase the cost of the procedure, the risk related to a improper functioning of the stapler.

Methods: We reviewed our prospectively maintained database analyzing patients from April 2015 to September 2017, who underwent robotic total gastrectomy with hand-sewn esophago-jejunostomy for gastric cancer.

Results: A total of 18 patients were included in the study. The mean estimated blood loss was 140 ml (60–257). The overall operative time was 365 min (277–421). Length of hospital stay was 6 days (5–13). No conversion was necessary nor anastomotic leakage occurred. The morbidity rate was 2/18 (11.1%) and included a subhepatic abscess and wound infection trough Pfannenstiel incision. A R0 resection rate was achieved in all cases. The mean of lymph node yield was 32 (14–39). The 1-year disease free survival was 74%, the 1-year overall survival 82.3%.

Conclusions: The robotic-assisted hand-sewn esophago-jejunostomy is a safe and no time-consuming technique. It avoids the complication related to the stapler firing and it offers cosmetic benefit to the patient in terms of extraction site.

V171—ROBOTICS & NEW TECHNIQUES—Flexible surgery


P.W.Y. Chiu Department of Surgery, The Chinese University of Hong Kong, HONG KONG, Hong Kong

Introduction: Colorectal endoscopic submucosal dissection (ESD) is increasingly practiced for treatment of early colorectal neoplasia. However, colorectal ESD is difficult to perform due to lack of retraction as well as instability especially over hepatic flexure. Dilumen EIP is an external flexible sheath introduced during colonoscopy to stabilize environment for ESD. This video demonstrated the use of Dilumen EIP for performance of colonic ESD at the ascending colon

Method and Results: This is a 60 years old lady who received screening colonoscopy and found a 20 mm lateral spreading tumor (LST) Type 0 IIa lesion at ascending colon distal to ileocecal valve. Under general anesthesia, patient received colonic ESD using Dilumen EIP. Due to significant looping, the Dilumen device was introduced with the techniques of double balloon enteroscopy. After identification of the LST, the balloon in the front would be deployed to the proximal to the lesion while both balloons would be insufflated and created a stable environment. The ESD procedure started after submucosal injection with normal saline in mix with indigocarmine, epinephrine and hyaluronate. Mucosal incision was performed over the anal side of the lesion, and after adequate submucosal dissection, clips were applied to attach the mucosal flap to the sleeve of proximal balloon and achieved retraction. The submucosa was adequately exposed for dissection using Dual knife jet. This enhanced submucosal dissection especially at one area with significant fibrosis. After the procedure, complete closure of the mucosal defect was performed by clips and assisted by the front balloon. The pathology confirmed intramucosal adenocarcinoma with clear resection margins.

Discussion: The DiLumen EIP device stabilized the environment within the colon with the double balloon and provide adequate retraction for performance of colorectal ESD.

V172—ROBOTICS & NEW TECHNIQUES—Flexible surgery


M. Kondo Surgery, Kobe City Medical Center General Hospital, KOBE, Japan

Background: Robotic surgery has been widely spread all over the world, but robotic gastrectomy is not common and difficult because of complex anatomy and wide-ranging operation fields. In addition, it had been performed only under a few high-volume centers for reasons of the limitation of national health insurance in Japan, which means medical expenses not covered by insurance. The situation was changed from this April, so we started robotic gastrectomy to reduce complications more rather than laparoscopic gastrectomy. We report results and aim to present the methods in detail using da Vinci Si Surgical System.

Methods: We place five trocars, one is umbilical endoscopy port, and other four ports are placed at the reverse trapezoid, almost fan-shaped. Using the arm number 3, the organ can be lifted up so that sharp lymphadenectomy is able to be done by almost a scissor as the arm number 1 while applying the countertraction by the arm number 2. In order to achieve a clear and bloodless lymphnode dissection while maintaining the oncological safety, we think not only the ultrasonic coagulating scissor but also the electrocautery of the scissor is very essential in robotic surgery. Less postoperative complication such as pancreatic fistula or pancreatitis might be derived from robotic surgery because we can avoid pressing the pancreas during the suprapancreatic dissection of lymph nodes. The Billroth I reconstruction can be performed using da Vinci EndoWrist stapler under stable and inflexible surgical fields without needing help of surgical assistant.

Results: From October 2017 to December 2018, 25 patients with gastric cancer were operated robotic gastrectomy, included 3 total gastrectomy. There was no conversion to open surgery and no conversion to other procedures derived from intraoperative complications, and the overall operation time is gradually decreasing from the 14th case.

Conclusions: We are now on the way of learning curve shortening operation time, but robotic gastrectomy is no less safer and adequate than laparoscopic surgery. We will show our robotic procedures including lymphadenectomy around subpyloric and suprapancreatic area, and reconstruction with several important points in our video

V173—ROBOTICS & NEW TECHNIQUES—Flexible surgery


S.H. Kang, Y.S. Cho, S.H. Min, Y.S. Park, S.H. Ahn, D.J. Park, H.H. Kim Department of Surgery, Seoul National University Bundang Hospital, 13620, Korea

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 mins. 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.

V174—ROBOTICS & NEW TECHNIQUES—Flexible surgery


A. Arezzo, M. Morino Department of Surgical Sciences, University of Torino, TORINO, Italy

The video shows a case of Laterally Spreading Tumour of the rectum with preoperative benign histology, Paris Classification 0-Is G (granular type), uT0N0 EUS stage, Kudo type IV, NICE type 2. The neoplasm measured 6 x 7 cm, and extended from 6 to 12 cm from the anal verge, mainly located on the posterior wall. According to our local policy the indication was a transanal full-thickness excision. This was performed with the Medrobotics Flex® Robotic System, used here for the first time outside the United States.The system technology utilizes an articulated multi-linked scope that can be steered along non-linear, circuitous paths in a way that is not possible with traditional, straight scopes. The maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. This enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. With the Flex® Robotic System, Surgeons can operate through a single access site and direct the scope to the surgical target. Once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. The system includes on-board 3D HD visualization. The Flex® Robotic System contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation.The video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a V-Lock 3/0 thread. While illustrating the technique the authors will comment pros and cons of the use of the device.



L. Morelli, M. Palmeri, N. Furbetta, G. di Franco, D. Gianardi, G. Stefanini, S. Guadagni, C. d’Isidoro, M. Bianchini, G. di Candio, F. Mosca Department of Surgery, University of Pisa, PISA, Italy

Background: Hepatobiliary procedures using a minimally invasive approachare demanding, especially in major hepatectomies. The use of da Vinci surgical System allows to overcome some of the kinematics limitations of the direct manual laparoscopy maintaining the potential advantages of a minimally invasive approach . We herein present a case of left hepatectomy and local lymphadenectomy for hepatocellular carcinoma, carried out with the use of the da Vinci Xi.

Methodology: A 72-years old man with a long-lasting HBV chronic infection and CT scan and MRI finding of a 4-cm solid neoplasia of the left hepatic lobe and gallbladder stones, was operated with the da Vinci Xi platform. The patient was placed in a supine position, with 15° anti-Trendelenburg inclination. The trocars were positioned according with the Intuitive indication for the upper quadrants surgery.

Results: The procedure was successfully completed in 360 min.At first, an intraoperative US scan with the use of Tile-Pro technology was done to determinate the tumor extension. The hepatic parenchyma transaction and the local lymphadenectomy were performed with monopolar scissors and bipolar grasps. The left hepatic vein section was performed with an endoscopic vascular stapler. There were no surgical complications or need for conversion to laparoscopy or laparotomy. The post-operative course was uneventful and the patient was discharged 5 days after surgery.

Conclusion: The da Vinci Xi can facilitate some technically demanding procedures and ultimately widen the range of application of minimally invasive surgery such as hepatic surgery. Besides the well- known advantages provided by robotic surgery on 3D imaging, increased range of motion and augmented surgical dexterity, one of the most interesting and innovative features of robotic technology is the digitalization of the operative view; furthermore the Tile-Pro multi-input display allows the surgeon a 3D view of the operative field along with the ultrasound exam for a precise understanding of anatomy and vascularity and of tumor location.



H. Konstantinidis, C. Charisis Robotic General and Oncologic Surgical Department, Interbalkan Medical Centre, THESSALONIKI, Greece

Aims: Minimally Invasive Techniques have well established their role in the field of hepatic surgery. During the last few years, robotic surgery as well, as the latest innovation of minimally invasive procedures, takes its position in this particular field with the benefits of overcoming the limitations of conventional laparoscopy. Our aim is to demonstrate the advantages of robotic surgery in procedures of hepatectomies, on occasion of a robotic hepatectomy performed by our team.

Methods: We present video fragments of a robotic left lateral hepatectomy procedure in an elderly female patient with a symptomatic gigantic haemangioma of the left hepatic lobe. We emphasize on the technical aspects and the advantages that the surgeon gains applying the robotic techniques in such procedures.

Results: The procedure was completed with minimal blood loss and the patient presented an uncomplicated post-operative course, with discharge on the third postoperative day, minimal need of analgesics and full recovery.

Conclusions: The excellent three-dimensional and high quality visualization that the robotic system offers, combined with the flexibility and the accuracy of the robotic instruments (especially on suturing), provide to the surgeon an important aid, in order to avoid serious complications, such as intraoperative bleeding and post-operative bile leaks. The restriction of the limitations of conventional laparoscopy is far more beneficial and promising for the evolution and the future of minimal invasive liver surgery.



L. Morelli, S. Guadagni, D. Gianardi, N. Furbetta, G. di Franco, G. Stefanini, M. Palmeri, C. d’Isidoro, M. Bianchini, G. di Candio, F. Mosca Department of Surgery, University of Pisa, PISA, Italy

Aims: The new da Vinci Xi surgical cart allows multi-quadrant and complex surgical interventions in a minimally invasive fashion. We present a case of robotic Appleby left pancreatectomy using this platform and its specific operating bed.

Methods: A 73-years old woman with CT scan finding of a 30-mm hypo-vascular neoplasm of the pancreas body underwent surgery with the use of the new da Vinci Xi with four arms upper quadrants trocar’ disposition.

Results: The procedure was successfully completed in 285 min. The pancreatic body was mobilized in order to expose the portal-mesenteric axis. The gland was transected using a robotic endo-stapler as well as the splenic vein. After evaluating the patency of collateral circles with intra-operative ultrasound, the common hepatic artery and the celiac artery were transected. Then we increased the right tilted position and the neoplasia was detached from the gastric body by a tangential gastric resection using the robotic endo-stapler. Finally, the operation was accomplished with the transection of the posterior attachment of the spleen and the pancreatic tail. No conversion or intra-operative complications were recorded. The post-operative course was uneventful and the patient was discharged 6 days after surgery.

Conclusions: The da Vinci Xi with its specific tools helps in performing challenging procedures such as Appleby operation for locally advanced pancreatic cancer. In our experience, the robotic endo-stapler permits the operating surgeon to directly control the transaction phase whereas the specific operating bed allows to perform minimally invasive multi-quadrant surgery and to obtain a better exposition of the operating field.



L. Morelli, N. Furbetta, D. Gianardi, M. Palmeri, S. Guadagni, G. di Franco, G. Stefanini, M. Bianchini, G. di Candio, F. Mosca Department of Surgery, University of Pisa, PISA, Italy

Background: The new technologies of da Vinci Xi system can facilitate minimally invasive surgery in challenging abdominal procedures such as pancreato-duodenectomy, making them easier and faster. We present a case of pancreatic neuroendocrine tumor (pNET) of the head of the pancreas treated with robotic Whipple procedure with the da Vinci Xi platform.

Methodology: A 76-years old man with a finding of a pNET of the head of the pancreas, underwent a robot-assisted pancreato-duodenectomy with the use of the new EndoWrist Vessel Sealer Extend and the da Vinci-Integrated Table Motion (dVTM) for the Xi system. Patient was placed in a lithotomy position. Robotic trocars were placed on the transverse umbilical line.

Results: The Whipple procedure was successfully completed in 570 min. Thanks to the dVTM the patient’s position changed during the intervention to improve the exposure, with the instruments left inside the abdomen and without undocking the robot. The dissection of the pancreatic head from the portal vein and the section of the retroportal lamina were performed with the use of the EndoWrist Vessel Sealer device. A personal modified end-to-side pancreatojejunostomy was carried out, with 5/0 Prolene and Gore-Tex double layer suture. No intra-operative complications occurred and no conversions to laparoscopy or laparotomy were required. The postoperative course was uneventful. Conclusions: The use of the new fully wristed Vessel Sealer Extend makes easier difficult maneuvers such as the fine dissection of the pancreatic head from the portal vein and the section of the retroportal lamina, enabling an optimized approach for vessels sealing and cutting and tissue bundles. Moreover, the dVTM allows patient’s movements without undocking the system or removing instruments from the abdomen, enhancing the surgical workflow.



M. Jureller 1, J. Yang2 1General Surgery, Montefiore Medical Center, BRONX, NY, United States of America; 2Gastroenterology, Montefiore Medical Center, NEW YORK, United States of America

Background: Necrotizing pancreatitis is a devastating illness which can develop in up to 20% of patients who suffer from pancreatitis. It carries great morbidity with an associated mortality rate between 8 to 39%. Many of these patients require drainage of fluid collections to treat sequela related to pain, per-os tolerance, and source control of sepsis if infected. The step-up approach to treatment of this disease has trended towards minimally invasive techniques, considering the morbidity of open debridement. As such, many centers have implemented the use of transgastric debridement via endoscopic cystogastrostomy. This technique, while effective in draining fluid and particulate necrotic tissue, has difficulty in resection of large necrotic tissue, due to instrument and anatomic limitations. Current endoscopic accessories designed for polypectomy or foreign body extraction, for example, are not optimal for performing necrosectomy. To overcome this obstacle, additional access sites can be utilized to assist debridement. We describe the first laparoscopic assisted transgastric endoscopic necrosectomy through a percutaneous gastrostomy in a 59 year old male with infected pancreatic necrosis secondary to biliary pancreatitis.

Aim: To investigate the feasibility of utilizing gastrostomy access to assist in debridement during endoscopic necrosectomy.

Methods: The patient previously underwent an open necrosectomy and gastrostomy tube placement for acute emphysematous pancreatitis. Post-operatively, there was a persistent and enlarging 12 cm infected walled-off necrosis (WON). Therefore, endoscopic cystogastrostomy was performed using a lumen-apposing metal stent.

Results: Frank pus was evacuated. Initial endoscopic necrosectomy was technically challenging due to the large volume of solid necrotic tissue. Repeat endoscopic debridement utilized a surgical laparoscopic grasper via the gastrostomy site to aide solid debris extraction (video). This allowed for complete necrosectomy and resolution of the WON. The patient did well and was discharged subsequently.

Conclusion: This is another emerging minimally invasive technique in the step-up approach for debridement and drainage of WON. The use of the gastrostomy as a utility port for accessory instruments not only enhanced the technical aspects of the procedure but increased its efficacy as well. Further experience is needed to validate the utility and reproducibility of this technique.



C. Gonzalez De Pedro, E. Perea Del Pozo, J. Tinoco Gonzalez, L. Tallon Aguilar, V. Duran Muñoz-Cruzado, A. Sanchez Arteaga, I. Ramallo Solis, F. Pareja Ciuro, J. Padillo Ruiz Cirugia General, Hospital Virgen Del Rocio, SEVILLA, Spain

Objective: The presentation of the minimally invasive surgical approach for pancreatic necrosectomy guided by videoretroperitoneoscopy or VAR (Video Assisted Retroperitoneoscopic), established in our center, as one of the option of the step-up approach treatment for acute necrotizing pancreatitis (ANP)

Methods: The placement of the patient on the operating table should be in decubitus, with right lateral inclination, at 20-30° on the horizontal surface.

The pancreatic cell is approached using the drainage catheter previously placed by radiological control (ultrasound or CT) as a guide, which will allow access to the cavity with safety.

An incision of 3-5 cm is made around the previously placed catheter, crossing the subcutaneous cellular tissue and muscular fascias, dissolving the musculature. It continues in a blunt dissection, until a loss of resistance is appreciated which generally coincides with the outflow of necrotic or purulent material.

Once the retroperitoneal cell is accessed, a 15 mm trocar is placed and a pneumoretroperitoneum is performed. The 15-mm trocar allows the joint use of a 5 mm and 0° optic and the surgical material that allows debridement and cleaning.

The aspiration and hydrodissection of the necrotic material, and the extraction of the solid component of the necrosis are proceeded.

Once the collection is drained and the necrotic material removed, a wash and drain system is placed, like a 3-way Foley type probe.

Conclusions: In conclusion, the VAR is an alternative surgical technique, valid and reproducible in the treatment of ANP, which offers comparable results and even superior, in some series, to those of open surgery, with satisfactory results in terms of morbidity and postoperative mortality.



T. Kusu, S. Nagaoka, Y. Nakahara, M. Hirota, T. Matsumoto, H. Takemoto, K. Takachi, S. Oshima Surgery, Kinki Central Hospital, ITAMI, HYOGO, Japan

Aim: Lung subsegmentectomy is suitable for small and deep, non-palpable lung nodules. Since it is difficult to intraoperatively detect the arteries, veins and bronchi of the subsegment, as well as the intersubsegmental borders, complete video-assisted thoracic surgery (VATS) for lung subsegmentectomy is challenging. We use preoperative three dimensional CT to detect the arteries, veins and bronchi of the subsegment before conducting complete VATS subsegmentectomy, and perform intraoperative bronchoscopy to detect the bronchi and intersubsegmental borders. I would like to describe our experience of complete VATS combined subsegmentectomy for a non-palpable lung nodule.

Methods and results: The patient was a 67-year-old woman. During health screening, a small ground-glass opacity was observed in her right lung on chest CT. The nodule was 15 mm in diameter and was located in S2b (horizontal subsegment of the posterior segment) near S3 (the anterior segment). We preoperatively diagnosed the lesion as well-differentiated adenocarcinoma, and planned combined subsegmentectomy for S2b and S3a (lateral subsegment of the anterior segment) of the right upper pulmonary lobe. Before the operation, the locations of vessels were confirmed by three-dimens