41ST WORLD CONGRESS OF SURGERY OF ISS/SIC

RELACION DE ABSTRACTS DE LA CATEGORÍA “ENDOSCOPIC SURGERY” Y PRESENTACIÓN ORAL EN EL 41ST WORLD CONGRESS OF SURGERY OF ISS/SIC

Durban (South Africa) Agosto 2005

 

Abstract ID: 3050
Category: Endoscopic Surgery
Mode of pres. : oral

Biliary tract injuries during laparoscopic cholecystectomy. Are we getting better? A comparative study

C. Georgiades, C. Zachariou, A. Papadomichelakis, K. Kakavias, I. Panagopoulos, E. Varada, G. Hatzikonstantinou. 3rd Surgical Department, Evangelismos Hospital, Athens, Greece.

Introduction: Biliary tract injuries during laparoscopic cholecystectomy is the main drawback of the technique compared to the open procedure. Most of the studies in the international literature indicate that the percentage of biliary tract injuries during laparoscopic cholecystectomy seems to stabilize instead of decreasing despite the accumulation of more experience. In this study our experience concerning biliary tract injuries during laparoscopic cholecystectomy is presented along with retrospective comparison of its’ incidence during our early versus our late experience with the technique.
Materials and Methods: Between 1991-2004, 1725 laparoscopic cholecystectomies were performed by various surgeons in our clinic. In the first 1000 operations, 8 biliary tract injuries occured, which included: 2 complete transections of the common hepatic duct, 1 laceration of the common bile duct and 5 cases of bile leakage through the drain. 2 of these 5 patients required re-operation where injury of the cystic duct was revealed in one case and injury of an accessory biliary duct of the liver bed was revealed in the other. In the following 725 operations, 7 biliary tract injuries occcured. Those concerned 1 patient with common bile duct stenosis, 3 patients with bile leakage through the drain, while 3 patients developed bile induced peritonitis. Of those with bile leakage, 2 required re-operation where injury of the cystic duct was revealed. In the patients with bile induced peritonitis, re-operation revealed 2 cases of injury of the cystic duct and 1 case of injury of an accessory biliary duct of the liver bed. 1 patient with bile induced peritonitis succumbed after developing multi-organ failure.
Results: The percentage of biliary tract injuries remains stable calculated at 0,87%. In comparing the early and late experience by chi-square test, no statistically significant difference is observed. The relative mortality of biliary tract injuries rose up to 6,6%, whereas the overall mortality due to the injury was 0,06%. This kind of complication contributes considerably to the increase in the morbidity of the procedure as well as the prolongation of the postoperative hospitalization while significantly raises its’ cost.
Conclusion: Despite acquiring more experience with laparoscopic cholecystectomy over time, the percentage of biliary tract injuries remains steady. The long-term consequences in the health of these patients due to this complication remain unknown.

Abstract ID: 3020
Category: Endoscopic Surgery
Mode of pres. : oral

Caroli´s disease-experience in 33 patients

P.L. Lamesch (1), W. Kassahun (1), CH. Wittekind (2), U. Pietsch (3), L. Schaffranitz (3), J. Hauss (1). (1) Visceral-, Transplantations-, Thorax- und Gefäßchirurgie, (2) Institut für Pathologie, (3) Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universität Leipzig.

Introduction: The first case of intrahepatic bile duct cyst was published by Vachel in 1906. 1958 Caroli described this disease as particular entity of bile duct disease. The disease includes segmental, uni- or bilobar intrahepatic bile duct cysts. More than 200 cases (25% unilobar) were decribed in the literature, mostly as case reports. The personal experience includes 33 patients who underwent an elective surgical treatment.
Materials and Methods: Between 5/1993 and 6/2004 641 liver resections (LR) and 287 liver transplantations (LTX) in 252 patients (pat.) were performed in our department. 33 pat. had Caroli´s disease. In 29 pat. (age: median 61.5, Range 26-77 y) indication for LR was bilobar n=6, unilobar (n=15) and segmental (n=8) involvement of the intrahepatic bile ducts. In a 27 y old pat. a cholangiocellular carcinoma (CCC) was diagnosed. The typical cystic dilatations were found in 15 cases in the right, in 14 in the left liver lobe. The following LR were peformed: segmental n=2, hemihepatektomie n=15, extended hemihepatektomie n=1. In 8 cases a LR and hepaticojejunostomy was required. 2 patients required LTX because of an extended bilobar dis-ease (in a 8 y old child with liver cirrhosis, recurrent variceal bleeding and emergency Warren-Shunt).
Results: The 30-day mortality rate after LR was 3% (1/33), morbidity was 15%. One pat. died from tumor recur-rence (CCC) 14 months after LR. 28 pat. after LR and a median follow up of 55 (range 3-53) months are in good general condition, 1 pat. after and LR and hepaticojejunostomy suffered from postoperative epi-sodes of cholangitis, without radiologic finding. The 2 pat. 29 - 48 months after LTX are without any complaints and stable graft function.
Conclusion: The diagnosis of Caroli´s-disease frequently is delayed more than 10 years after the first symptoms oc-cured. The potential risks of malignancy in cystic dilatation of bile ducts needs to be considered for the treatment of Caroli´s-Syndroms, although in this series only 1 CCC was diagnosed. In the presence of unilobar cystic dilatations LR is the treatment of choice for definitive cure. In the presence of bilobar cystic dilatations LR frequently may be only palliative; in these cases only LTX allows definitive cure.

Abstract ID: 3023
Category: Endoscopic Surgery
Mode of pres. : oral

Early introduction of laparoscopic colon surgery in residency

S. Daetwiler, M. Adamina, O. Schöb. Chirurgische Klinik, Limmattalspital, Schlieren, Switzerland.

Introduction: Laparoscopic colorectal surgery is coming out of age. Thus, the laparoscopic sigmoid resection (LSR) has become the standard procedure for elective diverticulosis surgery. Nevertheless, many teaching hospitals require extensive experience in open surgery prior training in LSR is initiated. We asked whether LSR might be teached safely to residents at an early stage of residency without jeopardy.
Materials and Methods: All sigmoid resections for diverticulosis in a single center were prospectively recorded into a dedicated database following the national standards of the Working Group for Quality Assessment in Surgery (AQC). Length of hospital stay, operative time, operative blood loss, conversion rate and perioperative morbidity and mortality were recorded. The diverticulosis was staged according to Hansen and the perioperative risk was assessed by the ASA classification. The surgeons performing LSR were stratified in 5 groups according to their experience in LSR. For the surgeons accounting less than 5 LSR (groups A and B), experience in open colorectal surgery (OCR) was taken into account. The first 5 LSR were teached by an experienced surgeon. From 5 LSR up, the surgeons began to operate independently. Following strata were analyzed: A: LSR 0-5 / OCR <10; B: LSR 0-5 / OCR >10; C: LSR 5-10; D: LSR 10-30; E: LSR >30. Statistical analysis was performed with Kruskal-Wallis ANOVA, Fischer exact test and Mann-Whitney U test. Significance was set at p<0.05.
Results: 197 consecutive elective and urgent sigmoidectomies for diverticulosis were prospectively recorded over 5 years (1.6.1999 - 31.5.2004) in a single community based teaching hospital. The data collection was complete in all cases. The overall conversion rate was 7.6% (15/197), leaving 182 cases for the present analysis. 12 surgeons operated, of them 10 were residents initiating training in LSR with different experiences in OCR. The overall morbidity and mortality showed no difference between groups (intraoperative complications: 2.7% (5/182); postoperative morbidity 6.0% (11/182); mortality 0.5% (1/182)). No differences were found between groups in age, gender, ASA classification and stage of diverticulosis. Upon progression of operative experience, residents gained independence. Operative teaching assistance was necessary in 19% of LSR in group C, 20% of LSR in group D and 0% of LSR in group E. Operative times were significant longer in groups A to D (A 264min, B 236min, C 283min, D 220min, p<0.001) as compared to group E (153min). Moreover, operative time of group D (220min) was significant shorter than group C (283min), p=0.03. Operative blood losses in groups A to D (A 231ml, B 110ml, C 326ml, D 175ml) were higher than for group E (103ml), p<0.002. The group C begins to operate independently and showed more blood losses than groups B, D and E, p<0.02. Groups A (3/19; 19%) and B (8/30; 27%) showed more conversions to OCR than group E (2/118; 2%); p<0.02. The other groups showed similar conversion rates (C 4.5% (1/22), D 9% (1/11)). Indications for conversion were sigmoid perforations (7/15, 47%), followed by adhesions (6/15, 40%), fistulas (1/15, 6.5%) and hemodynamic instability at anesthesia initiation (1/15, 6.5%).
Conclusion: LSR can be teached safely even with limited experience in OCR. Operative independence can be gained early without jeopardy into the bounds of a structured residency program. Thus, residents may begin to operate independently after as little as 5 LSR. Moreover, a threshold in the learn curve was identified after about 30 LSR.

Abstract ID: 2612
Category: Endoscopic Surgery
Mode of pres. : oral

Impact of polypropylene (PP) amount on functional outcome and quality of life after laparoscopic hernia repair using pure, mixed and titanium coated PP meshes

R. Horstmann (1), D. Palmes (2). (1) Chirurgische Klinik des Herz-Jesu-Krankenhauses Hiltrup, Münster, Deutschland, (2) Klinik für Allgemeine Chirurgie der Universitätsklinik Münster, Münster, Deutschland.

Introduction: Laparoscopic hernia repair requires the use of biocompatible materials. A prospective, single-center study was conducted to compare three meshes differing in the amount of polypropylene.
Materials and Methods: 673 consecutive patients with primary inguinal hernia undergoing laparoscopic hernia repair (TAPP) using a heavyweight PP mesh (Prolene® 10x15cm, 1,5g, group I, n= 232), a mixed PP- and Polyglactin mesh (VyproII®, 10x15 cm, 0.53g, group II, n=217) and a light-weight titanised PP mesh (Ti-Mesh®, 10x15cm, 0.24g, group III, n=224) were compared according to postoperative complications (seroma, wound healing disorders), quality of life score (pain development, physical condition, urologic disorders) and hernia recurrence (T-test, α<0.05).
Results: In a follow-up of 6 months no significant differences according to the recurrence rate (I: 4/232, II: 3/217, III: 3/224) occurred. Patients with a pure PP mesh (group I) showed significant more postoperative seroma (I: 28/232, II: 9/217, III: 4/224), foreign body sensations (I: 21/232, II: 12/217, III: 8/224) and meteor sensitivity (I: 13/232, II: 7/217, III: 5/224) compared to group II and III. In all groups the quality of life score could be improved postoperatively (preoperative points: I: 4.8±2.5, II: 4.7±2.5, III: 5.4±2.8; postoperative points: I: 1.2±3.0, II: 1.2±3.3, III: 1.1±1.7). However, regarding only patients with few preoperative complaints (preoperative points: I: 1.5±1.1, II: 1.3±1.3, III: 1.7±1.2) the postoperative quality of life was worsened when heavy weight PP meshes (group I+II) were used, but could significantly be improved by using light-weight titanised PP meshes (group III) (postoperative points: I: 4.1±4.9, II: 4.0±5.4, III: 0.8±1.9).
Conclusion: A reduction of PP amount in meshes for laparoscopic inguinal hernia repair is associated with comparable functional results and lower postoperative complications compared to heavyweight meshes. In particular, patients without any or only few preoperative complaints profit by lightweight PP meshes which are coated with titanium due to a significant gain in postoperative quality of life.

Abstract ID: 3085
Category: Endoscopic Surgery
Mode of pres. : oral

Laparoscopic Antireflux Surgery: Total or Partial Fundoplication?

K.S. Vasilev, P.G. Ivanov, G.B. Gurbev, G.B. Grigorov. Military Medical Academy, Clinic of Endoscopical Surgery.

Introduction: Several findings suggest that gastroesophageal reflux disease (GERD) has a significant impact on patients’ quality of life. The aim of this prospective study was (a) to evaluate and compare quality-of-life data before and after laparoscopic antireflux surgery (LARS) in GERD patients with and without Barrett’s esophagus (BE); and (b) to compare quality-of-life data of these patients to normative data for a comparable general population.
Materials and Methods: The Gastrointestinal Quality of Life Index (GIQLI) was administrated to 75 BE patients and to 174 patients with GERD without BE (Savary-Miller classification: grade 1: n = 49; grade 2: n = 69; grade 3: n = 56). The questionnaire was given to all patients preoperatively, 3months, 1 year, and 3 years after laparoscopic "floppy" Nissen fundoplication.
Results: Before surgery, BE patients (mean: 96.8 ± 9.3 points) had a better but not significant (p<0.06) general score of the GIQLI when compared with patients without BE (mean: 86.4 ± 10.1 points). This difference is solely based on the subdimension "gastrointestinal symptoms" which means that GERD symptoms are less intensively and frequently recognized in BE patients than in patients without BE. There are no other differences in the other four subdimensions of the GIQLI between both groups. Three months, 1 year, and 3 years after LARS, GIQLI was significantly (p<0.01) improved in both groups (BE patients mean after 3 years: 121.9 ± 8.2 points; non-BE patients mean after 3 years: 122.8 ± 9.3 points). This improvement was significantly better (p<0.05) in patients without BE than in BE patients. Before surgery, both groups scored significantly below average on all subscores of GIQLI compared to general population (mean: 122.6 ± 8.5 points). After surgery, there are no differences detectable.
Conclusion: As our data show, non-BE patients undergoing LARS achieve a better quality-of-life improvement than those patients with BE. However, after surgery GIQLI of both groups is comparable to the mean value of general population. This means that LARS is able to improve quality of life significantly in all GERD patients, with and without BE.

Abstract ID: 2516
Category: Endoscopic Surgery
Mode of pres. : oral

Laparoscopic inguinal hernia repair; A reviev of 4400 cases

I. Baca, L. Grzybowski, I. Soldo. Klinik fuer Allgemein-, Viszeral- und Unfallchirurgie Klinikum Bremen Ost, Bremen, Germany.

Introduction: A prospective study was performed to evaluate the safety and efficiency of laparoscopic hernia repair in our hospital.
Materials and Methods: Since 1993 4400 consecutive laparoscopic transabdominal hernia repairs ( TAPP) were performed at 3372 patients. There were 1028 bilateral, 1271 right and 1076 left hernia.Mean age was 59 years, we used a mesh of 12x15 cm.
Results: Operating time varied between 11 and 105 minutes with an meantime of 32 minutes. We had a recurrence rate in our population of 1,03 %. There were 158 complications ( 3,6% ). We saw one bladder two small bowell injury, which needed conversion to laparotmy and 3 of 38 hematomas required open exploration. 6 patients were reoperated because of nerve irritation and incriminated clips were removed with good postoperative result. An incarcerated trocar hernia occured in 6 cases. There was two wound infect at the umbilical incision. One mash infection with open mash extirpation.No incompatibility reaction to the mesh was observed. There was a significant decline over time in our complication rate. We found innitialy 27 complications in the group of the first 200 cases (13,5%)m the corresponding rate at presents is 2%. At the same time the rate of recurrency decreases with growing experience in laparoscopic hernia repair.
Conclusion: Laparoscopic hernia repair can be safely performed, the rates of recurrences and complications are low. Our experience with this technique shows good results combined with the benefits of minimal invasive procedures. In our clinic it is the method of choice in all age groups.

Abstract ID: 2095
Category: Endoscopic Surgery
Mode of pres. : oral

Laparoscopic manually assisted colonic surgery (LMACS)

B. Boldog (1), W. Schweizer (1), A. Steiner (2). (1) Department of Surgery,Kantonsspital Schaffhausen, (2) Gastroenterogy,Kantonsspital Schaffhausen.

Introduction: In comparison to laparoscopic procedures the conventional laparotomy for colonic resection offers an open direct view and a traditional high technical savety, but burdens the patient with mor and prolonged postoperative pain and a longer reconvalescence. To improve the safety of laparoscopic intervention, the use of a gridiron incision in the left lower abdomen, which is needed for specimen removal, is primarily used as an approach for the supporting hand of the surgeon and allows the use of the tactile feeling of the surgeons hand.
Materials and Methods: We report a consecutive and prospective study based on 119 patients, who underwent LMACS between November 1998 and November 2003. The results were compared to two historic groups of patients, who underwent conventional open rectosigmoid resection between 1993-1995 and 1996-1998. The aim of the study was to assess the results of LMACS reguarding operating time, intraoperative blood loss, duration of hospitalisation, postoperative return to normal enteral feeding and incidence of postoperative complications.
Results: There was no conversion to open surgery. The median operating time was 110 min. Anastomotic leakage occured in three cases, but could be treated twice in a second laparoscopic intervention by creating a new colorectal anastomosis. One patient was treated with fiberfree diet and antibiotics only conservatively. There was no need of colostoma. The main hospital stay was 8 days. Postoperative feeding was faster (87% within the first postoperative day) compared to the control groups, there was less intraoperative blood loss, fewer postoperative pain and a shorter hospital stay in the prospective groupe, all these values being statistically significant.
Conclusion: LMACS is a save procedure for rectosigmoid resection, with a short operativ time and a low rate of complications. Our results indicate, that the LMACS offers a very good comfort and better cosmetic results to the patients and confirm, that it is a save procedure, more than comparable to the open technique.

Abstract ID: 2927
Category: Endoscopic Surgery
Mode of pres. : oral

Laparoscopic suturing of the perforated gastroduodenal ulcers

Sh.K. Atadjanov, O.A. Kattabekov, K.S. Rizaev, KH.KH. Asomov. Republican Research Centre of Emergency Medicine.

Introduction: The purpose of our research is a studying of laparoscopic and endoscopic techniques and efficiency of its application in diagnostics and treatment of the perforated gastroduodenal ulcers.
Materials and Methods: Our clinic has experience of the ulcers laparoscopic suturing at 44 patients. There are 39 men and 3 found one ulcer of gastric localization and 43 DPK ulcers. Time between the moment of the perforation and operation oscillates from 2 to 12 o’clock.12 patients have not got any signs of the perforation on the X-ray examination. 25 patients had the diagnosis of the perforated gastroduodenal ulcers before the operation. 12 patients had not the diagnosis of the perforated gastroduodenal ulcers till the diagnostic laparoscopy. At 9 of them the diagnosis has been established due to the combined laparoscopic and endoscopic researches. Intraoperation gastroscopy with a gas insufflation helped to specify localization and the perforated ulcers sizes.
Results: The sizes of the perforated aperture changed from 2-3 mm up to 10 mm. Quantity of the outgoing gastric contents and reactive exudate varied from 50 ml up to 1200 ml. In addition serofibrinous peritonitis with diffusible spreading also took place. 4 patients had calluses ulcers in the frontal-upper wall of the duodenum. The suturing was carried out through all layers in one row at the small sizes aperture. In case of the big perforated aperture with the infiltration of edges the 2-rows suturing was applied. At 14 patients for achievement of tightness the 8-shaped suture on the perforated aperture was enough. At 24 patients was required the imposing of 2-knots suture. The stage of the suturing of the perforated apertures took 20 minutes; basic time was spending for sanitation of a belly cavity. At 6 patients was carried out combined laparascopic suturing of the perforated ulcers by the interoperation videotelegastroscopy. This method is allowed to define the suturing tightness, a degree of deformation and passage of the duodenum. Through irrigation system we wash out places of the greatest congestion exudate, fibrin with the subsequent aspiration. To the area of suturing is placed silicon drainage.In one case of the sutures insufficiency and peritonitis signs at the third postoperation day was performed the following operation: laparotomy and Bilrot resection first in modification of professor L.G.Hachiev.
Conclusion: Laparoscopic suturing of the perforated gastroduodenal ulcers has following advantages: early rehabilitation of patients, reduction of the postoperative period for 4 days, prevention of adhesive process, absence of postoperative hernias and suppurations, and also cosmetic effect. There are relative contra-indications for this method: huge ulcer with callous edges and diameter more than 1,0 sm., peritonitis in a terminal stage and impossibility of the belly cavity complete sanitation.

Abstract ID: 2373
Category: Endoscopic Surgery
Mode of pres. : oral

Morbid Obesity is the Cause of Chronic Abdominal Compartment Syndrome

E. Frezza, K. Shebani, J. Robertson. Texas Tech University Health Sciences Center.

Introduction: A newly recognized syndrome is the chronic compartment syndrome (CCS), which is hypothesized to be associated with morbid obesity.In this paper, we would like to demonstrate that morbid obesity causes CCS.
Materials and Methods: Between 8/11/2003 and 10/20/2004, 66 patients underwent laparoscopic gastric bypass surgery (LGBP) and 6 patients underwent laparoscopic adjustable gastric banding (LGB). The opening abdominal pressure was measured by connecting a verress needle to a pressure monitor. Retrospectively, we evaluated the data.
Results: Fifty-nine patients (82%) were Caucasian, 11 patients (15%) were Hispanic, 1 patient (1.4%) was native American and 1 patient (1.4%) was African American. There were 68 females (94%) and 4 males (5.5%). The mean age was 40±9.14. The mean body mass index (BMI) was 47±7. The mean weight was 284±49 (range 200-438). The mean opening pressure was 13.7±1.6 (range 10-18). The correlation of BMI, weight and abdominal pressure are reported in Table 1.

Conclusion: Morbid obesity is associated with (CACS). BMI correlates with the CACS in a direct proportional way. This study serves as a prelude to study the correlation between the severity of BMI and the number and severity of co-morbidities.

Abstract ID: 2865
Category: Endoscopic Surgery
Mode of pres. : oral

Outcome of laparoscopic rectopexy (Wells procedure) versus Gant-Miwa+Thiersch procedure in patients older than 70 years old

O.K. Okamoto, T. Kimura, K. Ohata, T. Saito, Y. Ide, Y. Higashi, K. Suzuki, A. Kawabe, H. Shimota. Fujinomiya City General Hospital.

Introduction: Rectal prolapse is more common in older patients who have coexisting diseases. Surgeons must consider less invasive and highly curative treatments. Gant-Miwa+Thiersch procedure (GMTP), one of the perineal approaches, is the most common procedure in Japan because it is low invasive. But its high recurrence rate can’t be ignored. Highly invasive procedures, such as the transabdominal approach have always been unpopular. Less invasive approaches, such as laparoscopic abdominal approach, recently became popular in many institutions. In 2001, we also started using the laparoscopic Wells procedure (LWP) for selected patients who can tolerate surgery under general anesthesia. This retrospective study compares the outcome between LWP and GMTP.
Materials and Methods: From 1992 to 2004, 18 patients underwent GMTP. From 2001 to 2004, 6 patients underwent LWP. The mean age was 79 (range, 74-85) in the LWP group and 79.6 (range, 71-90) in the GMTP group.
Results: The patients in both groups were predominantly female (LWP, 5/1; GMTP, 18/0). American Society of Anesthesiologists Scores in the GMTP group had a tendency to be higher than in the LWP group (P =0.059). The median operative time was longer in the LWP group than in the GMTP group (195 minutes vs. 86 minutes, respectively). Operative blood loss was very low and uncountable in both groups. Postoperative complications occurred in the LWP group with 2 cases of prolonged paralytic ileus and in the GMTP group with 3 cases of delirium. Postoperatively, start of oral intake (3.2 days vs. 3.1 days) and use of analgesic (0.8 times vs. 0.8 times) are even between the LWP group and the GMTP group. The median time for first bowel movement is longer in the LWP group than in the GMTP group (4.7 days vs. 2.6 days). Constipation, which was present in 3 patients preoperatively, affected 10 patients after GMTP. In the LWP group, although the number of constipated patients (3 patients) didn’t change, two patients became more constipated. But all of the 24 patients’ constipations were controllable with laxative. After LWP, incontinence improved in 4 patients, but the other two with weakened anal sphincter remained incontinent. The median postoperative hospital stay was shorter in the GMTP group than in the LWP group (9 days vs. 13 days). The median follow-up period was 43.9 months in the LWP group and 35 month in the GMTP group. The rate of recurrent prolapse in the LWP group had a tendency to be lower than in the GMTP group (0% vs. 16.7%)(n.s.).
Conclusion: Our results show that LWP is safe, has a low recurrence rate and the postoperative constipation is controllable. This procedure may become a suitable choice in rectal prolapse of elderly patients who can tolerate surgery under general anesthesia.

Abstract ID: 2181
Category: Endoscopic Surgery
Mode of pres. : oral

Preemptive analgesia with bupivacaine before and after creation of capnoperitoneum in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study

M. Barczynski, A. Konturek, R.M. Herman. 3rd Chair of General Surgery, Jagiellonian University College of Medicine, Krakow, Poland.

Introduction: To diminish the intensity of pain derived from central sensitization a preemptive analgesia was introduced to clinical practice. But the controversies exist regarding both the most appropriate analgesic agent and the optimum timing of the analgesia. The study aimed to evaluate the optimal timing of the preemptive analgesia in a prospective, randomized, double-blind, placebo-controlled study.
Materials and Methods: Throughout September 2003 and November 2004 one hundred and twenty consecutive patients referred to the 3rd Department of General Surgery for elective surgery of symptomatic non-complicated cholelithiasis who were qualified for laparoscopic cholecystectomy (LC) were randomized to 4 groups equal in size: Group A - received 1mg/kg of bupivacaine with epinephrine (Marcaine) diluted in 200ml of normal saline prior to creation of capnoperitoneum, Group B - received 1mg/kg of bupivacaine with epinephrine (Marcaine) diluted in 200ml of normal saline soon after the creation of capnoperitoneum, Group C - received 200ml of normal saline prior to the creation of capnoperitoneum and Group D - received 200ml of normal saline soon after the creation of capnoperitoneum. Local wound infiltration with bupivacaine was routinely used in all the patients prior to skin incisions. Having lifted the abdominal integument (groups A and C) the irrigation device was inserted through the umbilical wound and the solution was sprayed under the right and left hemidiaphragm, both over the liver and under the liver to spill around gallbladder and hepatoduodenal ligament. Whereas, in groups B and D the solution was sprayed in 3-5 minutes after creation of capnoperitoneum and soon after trocar placement. The postoperative intensity of pain was assessed in visual-analogue scale (VAS) 4, 8, 12, 24, and 48 hours after LC. Data were treated as parametric and analyzed with t-Student test. P<0.05 was considered to be significant.
Results: A significantly lower intensity of postoperative pain was observed during initial 24 hours in groups A and B. There were no remarkable differences in pain intensity between groups C and D. Group A reported lower pain level than group B in 4, 8 and 12 hours postoperatively (p<0.01; p<0.01; p<0.05, respectively) but the difference was non-significant after 24 and 48 hours.
Conclusion: The optimal timing of preemptive analgesia is before creation of capnoperitoneum. Although the effect of preemptive analgesia is also obtained when used soon after creation of capnoperitoneum, it brings significantly lower pain relief.

Abstract ID: 2978
Category: Endoscopic Surgery
Mode of pres. : oral

Subfascial Endoscopic Perforator vein Surgery, the first report of Iran

A. Jafarian, S.H. Emami Razavi, M. Neshati. Imam Khomeini Medical Complex, TUMS.

Introduction: Chronic venous stasis ulcer of leg is still a problem in vascular surgery. Innovation of new surgical techniques using endoscopic instruments made a new era with less complications and better results. This study is designed to evaluate the safety and long term outcome of this technique for the first time in Iran.
Materials and Methods: All patients with skin complications of chronic venous insufficiency were enrolled in the study from September 2001 to September 2003. Arterial disease and deep veins obstruction were exclusion criteria. Grade of the disease before operation, intraoperative finding and follow up exams were recorded. Patients were followed for a mean of 12.5 months.
Results: Subfascial endoscopic perforator veins surgery were done on 10 legs in 8 patients. The operation was done successfully in all patients. No serious complication occurred intraoperatively. There was no mortality or significant morbidity. Complete healing of skin ulcers was observed in 5 active and 2 healed ulcers in less than 12 weeks. We had 2 recurrences after 4 and 27 months, respectively.
Conclusion: Subfascial endoscopic perforator surgery is a safe procedure for treatment of venous stasis ulcers. Rapid ulcer healing could be expected in selected patients.

Abstract ID: 2347
Category: Endoscopic Surgery
Mode of pres. : oral

Surgical treatment of sportsman’s hernia and osteitis pubis by using extraperitoneal laparoscopic polypropylene mesh technique (TEP)

H. Paajanen (1), I. Airo (2). (1) department of Surgery, Central Hospital of Mikkeli, Mikkeli, Finland, (2) Deaconess Hospital of Helsinki, Helsinki, Finland.

Introduction: Sportsman’s hernia means a weakness or disruption of the musculotendinous part of the posterior inguinal wall. Osteitis pubis is characterized by pain, inflammation and sclerosis in the pubic symphysis. Both of these overuse injuries may cause persistent groin pain in athletes. They are often self-limiting diseases, but persistent pain may occasionally need surgery. A video-assisted placement of extraperitoneal synthetic mesh to support the damaged area may hasten the healing of these injuries.
Materials and Methods: 41 male athletes at national elite level (mean age 27 ± 7.1 years) with chronic groin pain resistant to conservative therapy were referred to surgery by sports clinics or club doctors. The majority of the patients were soccer (58 %) or ice hockey players (27%) at a professional level. The diagnosis was based on clinical findings, x-ray, magnetic resonance imaging (MRI) and isotope bone scanning.
Sportsman’s hernia was suspected in 36 patients and osteitis pubis in 5 patients. A 10x15 cm polypropylene mesh was placed into the preperitoneal space by using a totally extraperitoneal video-assisted technique. The severity of pain and the time to return to sports were determined after one month and after the mean follow-up of 4 years.
Results: On operation, no macroscopic abnormality was found within 24 patients (58 %), an obvious musculotendinous tear in 10 patients, and muscle asymmetry in 7 patients. Preoperative technetium bone scan revealed an enhanced isotope uptake of pubic bone in 5 patients of osteitis pubis. T2-weighted MRI indicated bone marrow edema in osteitis pubis, which was decreased postoperatively on repeated MRI scans. No complications were associated with the insertion of mesh. All except 2 patients (95 %) returned to their sport activites after one month of convalescence. No immediate or long-term complications were associated with the operation.
Conclusion: When conservative treatment fails, the placement of retropubic mesh is safe and mini-invasive method to hasten the rehabilitation of sportsman’s hernia and osteitis pubis in selected cases. The postoperative recovery was uneventful, and the patients returned rapidly to their sporting activities.

Abstract ID: 3108
Category: Endoscopic Surgery
Mode of pres. : oral

The outcome of Laparoscopic Cholecystectomy in the geriatric population

N. Salemis (1), A. Emmanouilidou (2), A. Chrysikou (1), P. Stavrinou (1), K. Nazos (1), E. Tsiambas (3), A. Karameris (3), E. Tsohataridis (1). (1) 2nd Department of Surgery, 417 Veterans Hospital (NIMTS), Athens, (2) Department of Clinical Cytology, 417 Veterans Hospital (NIMTS), Athens, (3) Department of Pathology, 417 Veterans Hospital (NIMTS), Athens.

Introduction: The aim of the study is to determine the safety and outcome of Laparoscopic Cholecystectomy in patients aged 70 years or older.
Materials and Methods: The records of all patients over 70 years old who underwent Laparoscopic cholecystectomy over the past five years were reviewed. This group consisted of 129 patients, seventy-five (58.1%) of whom were male and 54 (41.9) female (range 70 to 82 years). The indications for Laparoscopic Colecystectomy were uncomplicated symptomatic cholelithiasis in 90 (69.8%) patients, acute cholecystitis in 20 (15.5%) patients, gallstone pancreatitis in 10 (7.7%) patients, and various conditions in 9 (7%) patients. The preoperative evaluation included clinical history, physical examination, and laboratory studies such as blood count, liver function tests, amylase, clotting studies, chest X-Ray and ECG. Ultrasound imaging was performed in order to confirm the presence of gallstones and to evaluate the bile ducts for dilatation and stones. Preoperative ERCP was performed in selected cases. The preoperative evaluation revealed that 32% of the patients were at increased cardiac risk due to various reasons (history of myocardial infarction, arrhythmias, hypertension, various ECG abnormalities), 20% had increased pulmonary risk (history of chronic obstructive pulmonary disease, cigarette smoking, various symptoms of respiratory diseases, obesity), while 25% of the patients had diabetes. All patients received antibiotic prophylaxis together with prophylaxis against thromboembolic disease
Results: There was neither intraoperative nor postoperative mortality. Total morbidity was 7.7%. Five patients developed ECG abnormalities, four developed respiratory infections, while in one patient a laparotomy was required in the 10th postoperative day due to a biliary leakage. There were no major complications, such as common bile duct injuries, massive bleedings, or sub hepatic abscesses. Conversion to the open procedure was necessary in six (4.6%) patients. The reason for the conversion was a difficulty in understanding the anatomy due to the presence of severe adhesions in four patients, and a minor intraoperative bleeding that could not be managed laparoscopically in two patients. The median postoperative hospital stay was 3.1 days.
Conclusion: Laparoscopic cholecystectomy can be performed safely in the geriatric patients. The preoperative evaluation of these patients is of great importance, as this age group may have a number of coexisting diseases, the correction of which is mandatory.

Abstract ID: 2794
Category: Endoscopic Surgery
Mode of pres. : oral

The use of fibrin sealant for prosthetic mesh fixation in laparoscopic transabdominal preperitoneal hernia repair

J.M. Langrehr, S.C. Schmidt, P. Neuhaus. Klinik für Allgemein-, Visceral- und Transplantationschirurgie, Charité, Universitätsmedizin Berlin, Campus Virchow Klinikum, Deutschland.

Introduction: Laparoscopic inguinal hernia repair offers more rapid recovery and less pain than with the traditional open approach. However, injury to the nerves of the lumbar plexus with subsequent chronic pain or neuralgia has a reported incidence of 2% during laparoscopic hernia repair, particularly when the transabdominal preperitoneal technique (TAPP) is used. These complications are inherent to the use of staples for fixation of the mesh. To avoid nerve irritation, we considered the use of fibrin sealant for the fixation of the mesh instead of staples. The aim of this study was to evaluate this technique and to compare the short-term follow-up of these patients with patients who underwent the staple repair technique.
Materials and Methods: Between September and November 2004, we performed 17 consecutive laparoscopic hernia repairs (TAPP) in 14 patients (3 bilateral hernias) with primary hernias. The prosthetic mesh was fixed (10x15 cm) with 1 ml fibrin sealant. The fibrin was applied using a special laparoscopic applicator. The peritoneum was closed with absorbable sutures. The postoperative course of these patients was compared with that following staple fixation by matched-pair analysis.
Results: Patients were evaluated at a mean follow-up of 2.5 months (1.9-4.3 months). All patients underwent postoperative physical examinations. No recurrent hernia was found. There were 2 seromas and one hematoma in the stapled group. In the stapled group, one patient had pain in the area of the lateral femoral cutaneous nerve. There was no postoperative complication in the non-stapled group.
Conclusion: Fibrin fixation of the mesh during laparoscopic transabdominal preperitoneal inguinal hernia repair is feasible without higher risk of recurrences. In addition the fibrin fixation method may decrease postoperative neuralgia and reduce the incidence of postoperative seromas and hematomas.

Abstract ID: 2687
Category: Endoscopic Surgery
Mode of pres. : oral

Thyroidectomy Through A Small Incision versus Video-assisted Thyroidectomy

T.-C. Chao (1,2), J.-D. Lin (1,2), M.-F. Chen (1,2). (1) Chang Gung University School of Medicine, (2) Chang Gung Memorial Hospital.

Introduction: Video-assisted minimally invasive thyroid surgery is becoming an alternative surgical method in the treatment of relatively small thyroid nodules. Video-assisted thyroid surgery needs more manpower than does conventional surgery. This study is to examine if thyoidectomy can be performed through a small incision without video-assistance.
Materials and Methods: Fifty-one patients with thyroid nodules were treated either by thyroidectomy through a 2.5 - 3.0 cm transverse cervical incision using conventional technique (Group A, 26 patients) or video-assisted thyroidectomy through a 2.0 - 2.5 cm incision with the assistance of a 3.3-cm laparosope (Group B, 25 patients).
Results: There were 46 women and 5 men, with a median age of 35.0 years. Group A patients were older than Group B (median age 40.5 years vs. 31.0 years). The median tumor size (3.8 cm vs. 3.5 cm) was not different between two groups. Final histopathology of Group A patients included nodular hyperplasia (16 cases), follicular adenoma (6 cases), and papillary carcinoma (4 cases). Histopathology of Group B included nodular hyperplasia (11 cases), follicular adenoma (10 cases), papillary carcinoma (3 cases), and follicular carcinoma (1 case). Operations for Group A patients included unilateral lobectomy (21 cases), total thyroidectomy (3 cases), lobectomy and contralateral lobectomy (1 case), and subtotal thyroidectomy (1 case). On the other hand, those for Group B patients included unilateral lobectomy (21 cases) and total thyroidectomy (4 cases). No death, massive hemorrhage, wound hematoma, wound infection, permanent recurrent laryngeal nerve injury, or hypocalcemia occurred in either Group A or Group B patients. Transient recurrent laryngeal nerve palsy occurred in one (4.0%) of the Group B patients but not in Group A patients. The patients of both groups were discharged home on the second postoperative day. The cosmetic result was considered to be excellent by all patients.
Conclusion: Further experience with larger number of patients is necessary to determine the actual incidence of operative complications of thyroid surgery through small incision. However, our results are encouraging and suggesting that thyroid surgery through a small incision may be used as an cost-effective alternative method in the treatment of relatively small thyroid nodule.

Abstract ID: 2382
Category: Endoscopic Surgery
Mode of pres. : oral

Vacuum assisted abdominal wall lift for minimal invasive surgery (M.A.S). A preliminary porcine study to evaluate safety, efficacy and feasibility

T. E. Udwadia (1), B. K. Kathrani (2), U. S. Gadgil (2), W. Bernie (3), V. M. Chariar (2). (1) Dept. of M.A.S. P. D. Hinduja National Hospital, (2) Regional R & D, Johnson & Johnson Medical, (3) Ethicon Endo Surgery Inc.

Introduction: Abdominal lift with CO2 insufflation is the established method for MAS in spite of its documented deleterious effects, stressing the shortcomings of previously described gasless abdominal wall lift methods. Based on the negative pressure ventilation technique used in the "iron lung" we created a gasless lift of the abdominal wall by creating a vacuum between the abdominal wall and a plastic shell configured on moulds of the pigs abdomen insufflated with CO2 at 12mmHg. It is essential that an air ingress tube be placed in the peritoneal cavity, via open entry to ENSURE that air enters the peritoneal cavity pari passum with vacuum lift and throughout the lift procedure to maintain an air filled work space at ambient pressure, temperature, humidity for MAS.
Materials and Methods: Study was divided into 3 groups: Group 1: The aims of this study were to document a) the feasibility of this method to create the lift. b) the adequacy of the intraperitoneal air space for MAS. c) the vacuum pressures in mmHg required to initiate the lift and maintain it during MAS d) any deleterious effects of vacuum on vital sign, biochemistry and histopathology of the abdominal wall and viscera. Group 2: In addition to all aims of Group 1 a different sub set of pigs underwent laparoscopic cholecystectomy or laparoscopic salpingectomy to assess the Ergo metrics of the device (plastic shell), hand instrument use and optimal port placements and laparoscopic assisted bowel resection. Group 3: This third subset of pigs were subjected to vacuum lift at extreme vacuum level (250 to 400mmHg) and application time (2 to 4 hours) to study long term(2 to 8 days), all aims as in Group 1.
Results: 1. Vacuum pressure required for creating the lift in firm apposition between the abdominal wall and shell was 100 to 150 mmHg to initiate the lift and 10 to 50 mmHg to maintain the lift during the procedure. 2. Safety: Continuous monitoring of all vital signs during the procedure, biochemistry and histopathology, post-procedure all confirmed no deleterious effects of lift. 3. Intraperitoneal Work Space: subjective and objectively by actual measurement comparison in CO2 insufflation lift and vacuum lift was compatible with MAS. 4. Procedure Time: was equivalent to that of C02 lift. 5 Personnel and Cost: The raison d’etre of this study was to help spread MAS in the developing world. Cost was a major factor under study and compared favorably. 6. Ergo metrics and surgeon convenience is an area which will require further modification and improvement with use and experience.

Abstract ID: 2302
Category: Endoscopic Surgery
Mode of pres. : oral

Video-assisted Thoracoscopic Thymectomy for Myasthenia Gravis

K. Toolabi. Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.

Introduction: Thymectomy is an effective, but radical therapy for myasthenia gravis (MG). More recently video-assisted thoracoscopic surgery (VATS) has been proposed as a less invasive and similarly effective technique for the treatment of MG.
Materials and Methods: Six patients underwent VATS thymectomy during the year 2004 in our institution. All except one underwent preoperative IVIG therapy. Four women and two men with a mean age of 24 years had a right-sided VATS approach to remove all anterior mediastinal fat and thymic tissue. No patient had associated thymoma.
Results: All procedures were performed successfully, with no conversion to sternotomy. We believed that complete thymectomy was achieved in all cases by examination of the thymic bed and resected specimen. The mean operating time was 168 minutes. There was no perioperative mortality and significant long-term morbidity. That patient who was not received pre-operative IVIG, developed post-operative myasthenic crisis required about 20 days of assisted ventilation, but she was eventually discharged in a good condition. The median post-operative hospital stay was 5 days with median post-operative chest drainage for 2 days. Evaluation of post-operative clinical improvement requires more follow-up time.
Conclusion: VATS provides a new, alternative approach to thymectomy and has several advantages over the other established techniques. By minimizing chest wall trauma, VATS causes less postoperative complications and pain, shortens hospital stay, and gives better cosmetic results. However, the true role of it in MG awaits long-term results.