Scientific Paper. THE EFFECT OF BODY MASS INDEX (BMI) ON PATIENT OUTCOMES FOLLOWING ROBOTIC DISTAL PANCREATECTOMY AND SPLENECTOMY
Sharona Ross, Iswanto Sucandy, Cameron Syblis, Kaitlyn Crespo, Valerie Przetocki, Prakash Vasanthakumar, Alexander Rosemurgy, Harel Jacoby
Objective: Obesity has increased over the past decade, et the correlation between BMI, surgical outcomes, and the robotic platform is not well established. This study was undertaken to observe the impact of elevated BMI on perioperative outcomes for robotic distal pancreatectomy and splenectomy.
Methods: With IRB approval, we prospectively followed 122 consecutive patients who underwent robotic distal pancreatectomy and splenectomy since 2012. Regression analysis was utilized to identify significant relationships with BMI. For illustrative purposes, the data are presented as median (mean±SD). Significance was determined at p ≤ 0.05.
Results: Of the 122 patients who underwent distal pancreatectomy and splenectomy 52% were women, 8th edition AJCC stages were: 0 (4%) IA (25%), IB (21%), IIA (15%), IIB (26%), III (1%), and IV (8%). Neither sex (p = 0.26) nor stage (p = 0.07) had a relationship with BMI. Median BMI of all patients was 28 (29 ± 6.1) kg/m2; 1 patient was underweight, 31 normal weight, 43 overweight, and 47 obese. BMI is inversely correlated with age (p = 0.05). However, estimated blood loss (p = 0.42), conversions to ‘open’ (p = 0.71), harvested lymph nodes (p = 0.97), tumor size (p = 0.26), intraoperative complications (p = 0.64), and operative duration (p = 0.36) were not significantly correlated with BMI. Neither length of stay (p = 0.71), postoperative complications with a Clavien-Dindo score of ≥III (p = 0.47), nor 30-day mortality (p = 0.31) were impacted by BMI.
Conclusions: Patients were generally overweight to obese women with stage IA or IIB malignancy. Utilizing the robotic platform, age had an inverse relationship with BMI, but BMI had no impact on the perioperative outcomes.
★ The Medical Educator Consortium Award for Best Scientific Paper
Video. ROBOTIC DISTAL PANCREATECTOMY AND SPLENECTOMY
Umashankkar Kannan, Natalie King, Zachary Brown, Ali Ahmed, Emily Sardinski, Zachary Oulton, Paul Toomey
Objective: This video is of a 73 year old woman with pancreatic adenocarcinoma who was undergoing surveillance CT scans for a history of colon cancer and was found incidentally to have a 2.5 cm mass in the body/tail of the pancreas. Endoscopic ultrasound with FNA was concerning for pancreatic adenocarcinoma. This video is to show that robotic distal pancreatectomy and splenectomies can be undertaken safely.
Methods & Procedures: This was undertaken with four robotic ports and an assistant 5 mm port.
Results: The patient did well postoperatively and was discharged on postoperative day 3. The tumor was found on final pathology to be a 3.7 cm pancreatic adenocarcinoma with a background of a borderline mucinous cystic neoplasm and negative nodal disease, T2N0M0 (Stage IB). Margins were microscopically negative for an R0 resection.
Conclusion: Robotic distal pancreatectomy and splenectomy can be safely undertaken for patients with pancreatic adenocarcinoma.
★ Honorable Mention: Best General Surgery Video
Video. ROBOTIC DISTAL PANCREATECTOMY AND SPLENECTOMY IN A PATIENT WITH NEUROENDOCRINE NEOPLASM
Emanuel A. Shapera, Sharona Ross, Iswanto Sucandy, Alexander Rosemurgy
Objectives: Neuroendocrine neoplasm requires resection to effect a cure. A minimally invasive approach can improve outcomes by attenuating postoperative pain, reducing blood loss and providing superior visualization and exposure. We present a case of robotic resection of a neuroendocrine neoplasm located in the tail of the pancreas. We hope the stratagems demonstrated can assist other surgeons in providing minimally invasive resection for their patients.
Methods & Procedures: 74 year old woman presented to the emergency department with abdominal pain. CT scan demonstrated a 2.6 cm pancreatic tail mass. Endoscopic ultrasound and fine needle aspiration revealed a neuroendocrine neoplasm without vascular invasion. She underwent Robotic Distal Pancreatectomy and Splenectomy after initiation of an Enhanced-Recovery After Surgery (ERAS) protocol.
Results: Operative duration was 4 hours. Splenic artery followed by vein was divided with clips and a robotic stapler. No blood transfusions were required. A moderately differentiated neuroendocrine neoplasm, T3N0 with negative margins was identified on final pathology. Patient recovered uneventfully with discharge home on postoperative day 3. Clinic follow up on postoperative day 13 confirmed healthy uneventful recovery.
Conclusion: Robotic resection, when utilized safely, provides adequate oncologic outcomes with good and quick postoperative recovery.
Video. ROBOTIC ASSISTED DUODENECTOMY (D3 & D4) FOR MYH ASSOCIATED DUODENAL POLYPOSIS
Kevin C. Choong, Marc A. Attiyeh, Aaron Lewis, Gagandeep Singh
Objective: The duodenum remains a challenging area for minimally invasive surgery. Here we present a case of robotic assisted duodenectomy for MYH associated duodenal polyposis who had a prior total abdominal colectomy and ileal pouch anal anastomosis.
Methods & Procedures: We describe here a robotically assisted D3 and D4 resection for a patient with two large endoscopically unresectable polyps. Gastroenterology was asked preoperatively to tattoo proximal and distal to the polyps to guide the resection. The patient was positioned supine. Four robotic trocars were placed in a transverse orientation at the level of the umbilicus with an additional assist port placed in along a Pfannenstiel incision line. The operation proceeded as follows: 1) extensive lysis of adhesions, 2) Kocherization of the duodenum 3) duodenal resection 4) esophagogastroduodenoscopy, and 5) side to side hand sewn duodenojejunostomy.
Results: We present a 52-year-old female with MYH associated duodenal polyposis and prior total abdominal colectomy who underwent a successful robotic assisted duodenectomy. Estimated blood loss was 50 ml. The patient was discharged home on postoperative day 6. Her final pathology revealed a 5.5 cm tubulovillous adenoma with focal high-grade dysplasia as well as an additional 2.6 cm tubulovillous adenoma with margins free of dysplasia or malignancy. The patient is currently doing well without issue.
Conclusion: Complex reoperative duodenal resections can be safely performed in select patients in centers with surgical expertise.
Scientific Paper. BILIARY DYSKINESIA - IS IT REAL?
Yarret Robles, Umashankkar Kannan, Zachary Brown, Natalie King, Emily Sardzinski, Zachary Oulton, Bradley Gaddis, Paul Toomey
Objective: Biliary dyskinesia is a functional gallbladder disorder that can cause significant biliary pain in the absence of gallstones or any structural pathology. The aim of this study was to evaluate if patients with biliary dyskinesia have abnormal gallbladder pathology and if symptoms resolve after cholecystectomy.
Methods and Procedures: Patients who underwent a cholecystectomy by a single surgeon between 2015 and 2019 with an ejection fraction less than 40% or greater than 80% were included. Clinical symptoms, radiologic findings and pathology were evaluated. The data collected are presented as median, mean +/- standard deviation.
Results: Four hundred and forty-two patients underwent cholecystectomy and 96 patients (22%) had biliary dyskinesia. The median age of patients with biliary dyskinesia was 48 years and 85 patients (89%) were women. The presenting symptoms were abdominal pain (98%), nausea (25%), and vomiting (13%). The EF was 15%, 20 +/- 20% (n = 91). Five patients (5/96) had hyperkinetic biliary dyskinesia (EF > 80%). The EF for the hyperkinetic biliary dyskinesia was 96%, 93 +/- 7%. Pathology was chronic cholecystitis (88), normal (5), and cholesterolosis (3). All symptoms resolved by postoperative follow up.
Conclusions: Patients who were symptomatic as a result of biliary dyskinesia had histologic evidence of gallbladder inflammation and had resolution of symptoms after cholecystectomy. Cholecystectomy is indicated for biliary dyskinesia.
Video. ROBOTIC RESECTION OF SEGMENT VIII HEPATOCELLULAR CARCINOMA IN A CIRRHOTIC LIVER
Emanuel A. Shapera, Iswanto Sucandy, Sharona Ross, Alexander Rosemurgy
Objectives: Hepatocellular carcinoma (HCC) requires resection to effect a cure. A minimally invasive approach can improve outcomes but must be weighed by challenging factors such as cirrhotic parenchyma and tumor location with difficult exposure, such as posterior or dome liver lesions. We present a case of robotic resection of HCC in a patient with a dome lesion and hope it can guide other surgeons when facing a similarly difficult case.
Methods & Procedures: 76 year old woman with cirrhosis from treated hepatitis C presented with abdominal pain. MRI identified a 3 cm lesion at Segment VIII consistent with HCC. She underwent robotic segment VIII resection. Anesthesia kept the central venous pressure below 5 mm Hg and reduced PEEP to 0 during parenchymal transection. A vessel loop was wrapped twice around the hepato-duodenal ligament and secured with a nasogastric tube and bulldog clamp in preparation for intra-corporeal pringle. Ultrasonography guided the planes of transection, with bipolar maryland forceps and vessel sealer utilized to divide parenchyma. Gentle dissection with curved forceps and clipping of hepatic veins reduced blood loss.
Results: Operative duration was 4 hours. Pringle maneuver was not utilized. No blood transfusions were required. No drain was placed. A moderately differentiated HCC was removed with at least 1 cm of negative margins. Patient was ready for discharge on postoperative day 3 but remained for 5 additional days due to unrelated heart arrhythmia.
Conclusion: Robotic resection, when utilized safely, is technically feasible in tumors within difficult to access and cirrhotic liver parenchyma.
Scientific Paper. RESEARCH PROGRESS OF HETEROTOPIC AUXILIARY LIVER TRANSPLANTATION
Objective: To explore the research progress of heterotopic auxiliary liver transplantation.
Methods: We collected more than 20 articles in Chinese and 15 articles in English in the past five years by using Wanfang, Zhiwang and PubMed databases, and analyzed them to summarize the unique advantages and difficulties of the operation.
Result: Compared with orthotopic liver transplantation, heterotopic auxiliary liver transplantation (HALT) has unique advantages. The advantages are that the operation does not require the removal of the patient’s original liver and provides an opportunity for restoration of the patient’s original liver function, that only a part of a healthy liver transplant is needed to maintain the body’s metabolism, and that the operation is simple and there is no anhepatic phase. At the same time, HALT is expanding its technological reach. It can reduce the risk of kidney transplant failure in patients with highly sensitized renal failure, and also help reduce the risk of small liver syndrome in patients with primary liver cancer who are undersized. What‘s more, HALT can reduce the risk of immune injury and coagulopathy after xenotransplantation. However, it faces problems such as blood flow competition between the two livers and the occurrence of acute rejection.
Conclusion: With the increasing research of HALT, HALT will play an indispensable role in various technical fields. Whether the scientific distribution of blood flow between the two livers and the monitoring of Perforin mRNA are the best means for early diagnosis of acute rejection remains to be explored.
Scientific Paper. THE USE OF A BARIATRIC PORT AS A LIVER RETRACTOR
Objective: To determine the utility and feasibility of using a bariatric port as a method of retraction for the left lobe of the liver during laparoscopic cholecystectomy.
Methods and Procedures: A 12 mm periumbilical (camera) port, 5 mm lateral subcostal (assistant) port, 5 mm medial subcostal (left hand working) port and 5 mm subxiphoid (right hand working) port was inserted. After the gallbladder had been dissected and removed, the lateral subcostal site thus became the left hand working port, the medial subcostal site became the right hand working port, and the subxiphoid site the assistant port. The 5 mm subxiphoid port was replaced with a bariatric port. This was used to retract the left lobe of the liver to reveal the cystic duct.
Results: Given that the cystic duct was particularly friable, it needed to be further secured after gallbladder dissection and removal. However the extensive fatty liver posed a challenge to exposure of the underside of the liver. The 5 mm subxiphoid port was removed and replaced with a bariatric port. The bariatric port could be used without further instruments to retract the left lobe of the liver and this allowed for sufficient working space and an unobstructed visualization of the angle of the cystic duct with the common bile duct. The cystic duct was then secured with a barbed suture and endoloop and the procedure completed with haemostats and skin closure. No gross liver injury or post operative complications were observed.
Conclusion: The technique did not require further incisions and was quick and feasible.
Scientific Paper. DEVELOPMENT AND PILOT TESTING OF AN INTRA-OPERATIVE SMARTPHONE APPLICATION WITH “CRITICAL VIEW OF SAFETY”-IMAGE-RECOGNITION AND TELE-MENTORING NETWORKING FUNCTIONS WHICH CAN HELP SURGEONS PREVENT BILE DUCT INJURY COMPLICATION DURING LAPAROSCOPIC CHOLECYSTECTOMY PROCEDURES.
Michael Dennis Isaias Dela Paz, Miguel C. Mendoza, Maria Minerva P Calming
Objective: Laparoscopic cholecystectomy, the gold standard treatment for symptomatic gallstones, has a treacherous risk of bile duct injury (BDI). Since 1995, a universal culture of safety for cholecystectomy was established through "Critical View of Safety" (CVS) which leads to various training and innovative programs whose main goal is to absolutely eliminate BDI. Gap still exists as estimated 3 out of 1000 cholecystectomies still lead to BDI. The main objective of this technical note is to harness the technology of Smartphone App which can help prevent BDI during laparoscopic cholecystectomy.
Method and Procedure: Development and internal validity analysis of a Smartphone Application that identify CVS intra-operatively through image recognition and involvement of the community of expert surgeons through real-time networking decision strategy can be of help to absolutely prevent BDI. A mock pilot testing using doublet view CVS pictures of previous known-outcome laparoscopic cholecystectomies of either a known safe cholecystectomy procedure or an unfortunate complicated cholecystectomy with bile duct injury. These pictures were analysed by both the image recognition function as well as the expert’s tele-mentoring networking function.
Results: Both the results of the image recognition as well as the answer of the expert surgeons are at par with accuracy and precision of identifying the critical view of safety although both complimented well to each other.
Conclusion: This surgical safety App is a feasible tool to prevent BDI in laparoscopic cholecystectomy. Further study needed for an actual patient safety use as an interactive zero bile duct injury timeout procedure.
★ Harrith M. Hasson Award for Best Presentation Promoting Education and Training
Scientific Paper. IMPROVED MORBIDITY, MORTALITY, AND COST WITH MINIMALLY INVASIVE COLON RESECTION COMPARED TO OPEN SURGERY
Hazim Hakmi, Leo Amodu, Patrizio Petrone, Michael Bourgoin, Toyooki Sonoda, Shahidul Islam, Collin Brathwaite
Objectives: Despite the growth of minimally invasive surgery in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections.
Methods: We analyzed outcomes between 2016 and 2018 using a comparative database with discharge and line-item data from more than 350 member institutions, including 97% of academic medical centers in the United States. Demographics, hospital length of stay, readmissions, complications, mortality, and costs were compared between patients undergoing elective open and minimally invasive colon resections. Continuous variables were assessed for normality and outliers using formal statistical, extreme observations, histograms, and probability plots. For bivariate analysis, wilcoxon rank-sum test was used for continuous variables and χ2 test was used for categorical variables.
Results: A total of 88,405 elective colon resections (Open: 56,599; minimally invasive: 31,806) were reviewed. A larger proportion of patients undergoing minimally invasive surgery were obese (Body mass index ≥30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). Open colectomies had a longer median length of stay compared with the minimally invasive approach [median (range): 7 (4–13) days vs. 4 (3–6) days, p < 0.0001], more 30-day readmissions [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041-23,094) vs. $9013 (6748 – 12,649), p < 0.0001].
Conclusion: Minimally invasive colon surgery has clear benefits, and the routine use of open colon surgery should be re-evaluated.
★ Michael S. Kavic Award for Best Scientific Paper by a Resident
Scientific Paper. LEARNING CURVE OF ROBOTIC TOTAL MESORECTAL EXCISION VERSUS TRANSANAL TOTAL MESORECTAL EXCISION: A SINGLE-CENTER STUDY
Martin P. Karamanliev, Tsvetomir M. Ivanov, Tatyana Betova, Sergey Iliev, Dobromir D. Dimitrov
Objective: To explore the learning curve of robotic total mesorectal excision (R-TME) and transanal total mesorectal excision (taTME) for rectal cancer. This work was supported by the European Regional Development Fund through the Operational Programme “Science and Education for Smart Growth” under contract BG05M2OP001-1.002–0010-C01(2018–2023).
Methods and Procedures: A single-center prospective-retrospective trial was done. The first ten consecutive R-TME patients between Mar 2016 and Oct 2017 were studied retrospectively. The first ten consecutive TaTME patients between Jun 2020 and Nov 2020 were studied prospectively. The intraoperative time, neoadjuvant treatment, conversion rate, ostomy creation, intraoperative and postoperative complication rate were studied.
Results: Mean operative time in the R-TME group was 309 min. Defunctioning loop ileostomy was done in 2 patients (20%), in one patient a Hartmann procedure was performed. One patient with bleeding as an intraoperative complication and one postoperative Clavien-Dindo 2 anastomotic leak was reported. The conversion rate was 20% (two patients). CRM was negative in all patients. A positive distal resection margin was confirmed in one patient. Mean operative time in the TaTME group was 278 min. Defunctioning loop ileostomy was done in 8 patients (80%), in one patient a Hartmann procedure was performed. One intraoperative complication was reported – a purse-string failure which was managed intraoperatively with no other intra- or postoperative complications. The conversion rate was 10% (one patient). R1 resection was confirmed in one patient.
Conclusion: The learning curve should be considered in all procedures. A structured training pathway is essential. No differences between robTME and TaTME in the learning curve were observed in our center.
Scientific Paper. MINIMALLY INVASIVE URGENT COLECTOMIES CONFER LOWER ADVERSE OUTCOMES COMPARED TO OPEN: AN ANALYSIS OF THE ACS NSQIP
Luv Hajirawala, Varun Krishnan, Claudia Leonardi, Elyse RBevier-RawlsGuy R Orangio, Kurt G Davis, Aaron Klinger, Jeffrey S Barton
Objectives: The use of MIS for urgent colectomies, defined as neither elective nor emergency, remains understudied. The aim of this study is to compare short-term outcomes following urgent MIS colectomies to those following open colectomies.
Methods & Procedures: The ACS NSQIP colectomy specific database was queried between 2013 and 2018. Patients who underwent elective and emergency colectomies, based on the respective NSQIP variables, were excluded. The remaining patients were divided into two groups, MIS and Open. MIS colectomies with unplanned conversion to open were included in the MIS group. Baseline characteristics and 30-day outcomes were compared using univariable and multivariable regression analyses.
Results: 29,345 patients were included in the analysis. Of these, 12,721 (43.7%) underwent MIS colectomy, and 16,624 (56.3%) underwent open colectomy. Patients undergoing MIS colectomy were younger (60.6 vs 63.8 years) and had a lower prevalence of ASA IV (9.9 vs 15.5%) or ASA V (0.08% vs 2%) (p < 0.0001). After multivariable analysis, MIS colectomy was associated with lower odds of mortality (OR = 0.63 0.52, 0.76 95% CI) and most short-term complications recorded in the ACS NSQIP. While MIS colectomies took longer to perform (161 vs 140 minutes), the length of stay was shorter following MIS colectomies (12.2 vs 14.1 days) (p < 0.0001).
Conclusions: MIS colectomy affords better short-term complication rates compared to open colectomy in the urgent inpatient setting. Though the present data are limited by selection bias, the benefit of MIS is clear. Whenever feasible, minimally invasive colectomy should be offered to patients necessitating colon resection in the urgent inpatient setting.
VIDEO/GENERAL SURGERY. ONE APPENDIX, THREE DIAGNOSES
Nisha Narula, Giovanni Bonomo, Karen E Gibbs, Lisa Y Shimotake, Indraneil Mukherjee
Objective: This purpose of this case presentation is to demonstrate a patient who had appendicitis, appendiceal intussusception, and appendiceal diverticula with a fecalith present in the cecum. It shows the importance of attention to subtle findings, as this can change management.
Methods and Procedures: This is a case presentation and no statistical methodology was required. The patient presented with abdominal pain and localized tenderness. The white blood cell count was 9,000 and a computed tomography (CT) scan showed appendicitis, cecal inflammation, and appendiceal intussusception.
Results: After initial nonoperative management due to inflammation of the cecum in addition to appendicitis, the patient underwent a colonoscopy that confirmed appendiceal intussusception. Subsequently, the patient was taken electively to the operating room after a bowel preparation. She underwent an appendectomy and partial cecectomy to include the fecalith. She was discharged home from the recovery room and was doing well at follow up in clinic.
Conclusion: This case demonstrates a rare instance where not only appendicitis, but appendiceal intussusception and diverticula were found on imaging and pathology with an associated fecalith present. It shows the importance of attention to imaging findings and intraoperative findings as management, in this case, a partial cecectomy in addition to the appendectomy, may be required.
Scientific Paper. COMPARISON OF OUTCOMES AND COSTS USING DIFFERENT LAPAROSCOPIC ENERGY DEVICES FOR APPENDECTOMY IN AN ACADEMIC HOSPITAL FROM A MIDDLE INCOME COUNTRY IN SOUTH AMERICA
Laura Gaitán, Anibal Ariza, Alfonso Marquez, Carlos Diaz, Lilian Torregrosa, Lina Marroquin
Objective: We aimed to evaluate the effects of using monopolar electrosurgery during laparoscopic appendectomy as an institutional policy on clinical outcomes and costs in an academic hospital from a middle income country in South America.
Methods & Procedures: Retrospective analysis of the institutional database including all the laparoscopic appendectomies performed from Jan 2014 until Dec 2018. We comparatively assessed the distribution of clinical outcomes by the different types of sealant energy used during the study period. We used Logistic and linear regression analysis to assess the relationship of the type of energy used and clinical outcomes and costs, respectively.
Results: A total of 2,074 laparoscopic appendectomies were included from which 57,2% (n = 1187) were performed using monopolar energy, 2,3% (n = 48) with bipolar energy, 8,6% (n = 179) with a vessel sealing device, and 31,8% (n = 660) with an ultrasonic device. The median age was 32 years. 71.5% (n = 1483) where acute uncomplicated appendicitis. There was no statistically significant difference between need of reoperation, surgical site infection rate or postoperative ileus. The use of monopolar energy significantly reduced the cost of the surgical procedure during the evaluated period.
Conclusions: The implementation of monopolar energy device is safe and has the same advantages as other energy devices with the additional benefit of being a much less costly device for the health system.
Video. CLINICAL IMPLICATIONS OF ANATOMIC VARIATIONS OF THE PRESACRAL SPACE
Tosin Odunsi, Gerald Feuer, Ceana Nezhat
Objective: To describe the presacral space and the spatial relationship between key anatomic landmarks, demonstrate anatomic variations in the presacral space, and discuss the clinical implications as they relate to minimally invasive surgery.
Methods & Procedures: Video description of key landmarks found in the presacral space, the fundamental steps of a presacral neurectomy, cases with anatomic variations of the presacral space, and clinical implications. Patients provided consent for the video and publication. This video with no identifying patient data was exempt from Institutional Review Boards Approval.
Results: The procedures that warrant dissection in the presacral space include presacral neurectomy, sacropexy, lymphadenectomy, and some instances of bowel mobilization. Once the presacral space is entered, there are key landmarks to note. In a presacral neurectomy, the peritoneum overlying the sacral promontory is elevated and a small opening is made. The peritoneum is incised horizontally and vertically, and the opening is extended cephalad to the aortic bifurcation. Retroperitoneal lymphatic tissue including the nerve fibers of the hypogastric plexus are skeletonized, desiccated, and excised. All of the nerve fibers within the boundaries of the Triangle of Cotte are removed to maximize patient outcomes. The clinical implications of anatomic variations are important to consider prior to abdominal entry and dissection of the presacral space.
Conclusion: The anatomic pattern of the presacral space is variable, major vessels may deviate significantly from their expected positions, and prior to entering the space, surgeons should be careful to have full exposure.
Scientific Paper. TO EVALUATE EFFECTIVENESS OF A PRAGMATIC, INTERDISCIPLINARY MODEL FOR ENHANCED RECOVERY AFTER SURGERY (ERAS) IN GYNAECOLOGICAL SURGERIES VERSUS CONVENTIONAL APPROACH: A RANDOMIZED CONTROLLED TRIAL
Anupama Bahadur, Payal Kumari, Rajlaxmi Mundhra
Objective: To evaluate effectiveness of enhanced recovery after surgery (ERAS) model versus conventional approach in benign gynaecological surgeries (incorporating various routes of surgery).
Methods & Procedures: Randomized Controlled Trial. Setting: Department of Obstetric sand Gynaecology, All India Institute of Medical Sciences, Rishikesh. Method: 160 patients undergoing gynaecological surgery for benign indications, from Jan 2019 to Jul 2020 were recruited and randomized into ERAS (n = 80) and Conventional Protocol (n = 80) group using Block Randomization. Primary Outcome: Median length of stay.
Results: “Fit for discharge” criteria was used to assess the length of stay in postoperative period as patients came from hilly terrain and transportation facilities were limited so they stayed for longer duration. Difference in length of hospital stay between ERAS (n = 90, median: 36 hours, range: 24–96 hours) and conventional group (n = 90, median: 72 hours, range: 24–144 hours) was significant (p < 0.01). Earlier recovery of bowel function (time to passage of flatus, p < 0.01 and time to defecation, p < 0.01) was noted in ERAS group. Patients under ERAS protocol tolerated diet earlier and the difference was statistically significant (p < 0.01). No significant difference in complications and readmission (within 30 days) rate was seen between ERAS and conventional group. Quality of Life as assessed by WHO-QOL BREF on Day of Discharge and Day-30. It was higher in ERAS group in Physical and Psychological Domain while no significant difference was seen in Environmental Domains and Social Domain.
Conclusion: Our study strengthens existing evidence regarding efficacy of ERAS in reducing hospital stay and improving quality of life compared to the traditional peri-operative management protocol.
★ Honorable Mention – Best Gynecology Scientific Paper
Scientific Paper. ANALYSIS OF RESPONSE TO THE COVID-19 PANDEMIC AND IMPACT ON GYNECOLOGIC SURGERY AT A LARGE ACADEMIC HOSPITAL SYSTEM
Shabnam Gupta, Parmida Maghsoudlou, Mobolaji Ajao, Jon I Einarsson, Louise P King
Objective: The COVID-19 pandemic dramatically impacted gynecologic surgery. In Mar 2020, the American College of Surgeons recommended delay of all nonessential invasive procedures. This study characterizes the number and types of procedures performed during the peak pandemic period.
Methods & Procedures: We conducted a retrospective cohort study, identifying all gynecological surgical procedures performed at Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital between 03/16/2020 and 07/31/2020, as well as cases during the same months of 2019.
Data was stratified by three time periods: in period 1 no nonessential procedures were advised, in period 2 urgent procedures could resume, and in period 3 full reopening was achieved.
Results: In 2019, 1,545 gynecologic cases were performed compared with 942 cases in 2020 (39.0% decrease). There was a 73.6% decrease in cases over period 1, a 20.1% decrease over period 2, and a 2.9% increase over period 3. Cases performed by gynecologic oncologists in 2020 accounted for 58.1% of all gynecologic cases over period 1, 29.4% of cases over period 2, and 33.3% of cases over period 3. In 2020, hysterectomy was the most commonly performed procedure, while surgery for endometriosis and uterine fibroids had the greatest decrease in volume. Among emergency procedures, more surgery for ectopic pregnancy was performed in 2020 compared with 2019.
Conclusion: Many women had significant delays in receiving gynecologic surgical care during the peak pandemic period. Further studies are indicated to determine the impact of this delayed care on patients’ quality of life and disease process.
Video. THORACOSCOPIC RESECTION OF TRANS-DIAPHRAGMATIC CONGENITAL PULMONARY ADENOMATOID MALFORMATION
Wendy Jo Svetanoff, Katrina L Weaver, Tolulope A Oyetunji
Case Presentation: A female infant was found to have a left infradiaphragmatic hyperechoic mass during prenatal ultrasound, concerning for neuroblastoma. After a full-term birth, a computed tomography scan revealed the mass to be in the left lung, with extension through a diaphragmatic defect into the left super-renal region. A feeding vessel was seen arising from the descending thoracic aorta. The final diagnosis was a left bronchopulmonary sequestration. On repeat imaging at six months of age, the mass had decreased in size and appeared to remain within the thoracic cavity.
Operative Intervention: The patient underwent thoracoscopic resection at 6 months of age. The mass was found to be within the left diaphragm with no lung association. The mass was resected using blunt and electrocautery dissection to separate the cystic lesion from the diaphragmatic muscle. The lesion appeared to be fully contained within the diaphragm and did not extend into the abdominal cavity. A feeder vessel to the mass was not identified. After complete excision, the diaphragmatic muscle was reapproximated with 2-0 silk sutures to completely close the defect. The patient was extubated immediately following the procedure. She was advanced to a regular diet by postoperative day #1 and discharge home the same day.
Conclusion: The final pathology revealed the lesion to be a Type II congenital pulmonary adenomatoid malformation. She has been doing well since initial hospital discharge.
★ Gustavo Stringel Award for Best Pediatric Surgery Presentation
Scientific Paper. LAPAROSCOPIC GASTROSTOMY DURING AN OPEN ABDOMINAL PROCEDURE: A NOVEL APPROACH IN PEDIATRIC PATIENTS
Kayla B Briggs, Charlene Dekonenko, James A Fraser, Wendy Jo Svetanoff, Rebecca M Rentea, Pablo Aguayo, David Juang, Richard J Hendrickson, Charles L Snyder, Shawn D St Peter, Tolulope A Oyetunji, Jason D Fraser
Objective: Infants with intra-abdominal pathology necessitating open abdominal surgery may require a gastrostomy tube for inadequate oral intake. A Stamm gastrostomy is often performed during an open abdominal procedure in adults however, laparoscopic g-tube placement can provide superior visualization with a more straightforward and familiar approach in pediatric patients. We describe a series of patients who underwent laparoscopic gastrostomy at the time of an open abdominal procedure.
Methods & Procedures: Retrospective review identified patients who underwent an open abdominal operation with concurrent laparoscopic gastrostomy from 1/2010-6/2020. The technique involves placement of the camera port between sutures of a partially closed open abdominal incision or through a separate umbilical incision after the abdomen is closed. Patients were excluded if gastrostomy was performed before the open procedure.
Results: Twelve patients were included with a median age of 10 weeks [IQR 6,14], a median weight of 4.1 kg [IQR 3.4,4.8], and 67% (n = 8) were male. See Table 1 for patient diagnoses, prior operations, and open procedure performed concurrent with the laparoscopic gastrostomy. Ten patients had the camera placed through the same incision while 2 had the camera placed through a separate incision. Median total operative time was 106 minutes [IQR 80,125]. There were no intraoperative complications. The most common postoperative complications were surgical site infection (n = 5) followed by gastrostomy leakage (n = 3). Tract disruption requiring interventional radiology replacement and malfunction requiring reoperation occurred in 2 patients.
Conclusion: Laparoscopic gastrostomy can be effectively performed during an open abdominal procedure, providing excellent visualization and a more straightforward operative approach the pediatric patient.
Global Perspectives Session. FERTILITY OUTCOMES AFTER SURGICAL MANAGEMENT OF ENDOMETRIOSIS
Objective: To review pregnancy rates after surgical management of endometriosis
Methods and Procedures: A literature search on PubMed was performed. All relevant articles including systematic reviews, meta-analyses, randomized control trials (RCTs) case-control studies, prospective and retrospective studies pertaining to fertility outcomes after surgical management of endometriosis were reviewed.
Results: For stage I and II endometriosis, there was a statistically significant improvement in pregnancy rates with ovulation induction and intrauterine insemination after surgical treatment. Pooled results show benefit in achieving successful pregnancy after operative laparoscopy compared to diagnostic laparoscopy, with the number needed to treat equal to 40 patients. For stage 3 and 4 endometriosis/deep infiltrating endometriosis (DIE), reported pregnancy rates after surgery ranged from 32% to 84.5%. Removal of bowel endometriosis seem to increase spontaneous and assisted reproductive technology pregnancy rates. However, surgical treatment of DIE prior to in vitro fertilization (IVF) does not seem to be beneficial. For women undergoing repeat surgery, lower pregnancy rates were achieved compared to after primary surgery. Pregnancy rates were significantly higher after 2 IVF cycles compared to repeat surgery. For women with failed IVF attempts, a pregnancy rate of 42.3% was achieved after surgical treatment mostly via IVF. As for endometriomas, surgical excision improved spontaneous pregnancy rates. However, there were no difference in pregnancy or live birth rates with surgical excision prior to IVF.
Conclusion: Though there may be some benefit towards fertility outcomes after surgical treatment of endometriosis, shared decision-making should be undertaken and individualized to each patient’s clinical situation.
A NOVEL LAPAROSCOPIC ENTRY PORT IN PREVIOUS SURGERY CASES: JAIN POINT
Objective: To study the safety and efficacy of Jain Point as first blind entry port in previous surgery cases.
Methods: It is a retrospective study undertaken at a high volume tertiary care referral center for advanced gynecological laparoscopic surgery. We advocate the concept of nonumbilical entry from a newly devised point, the Jain point, in the left para-umbilical position aiming at taking the first blind entry at a lower and lateral point, to avoid adhesions around umbilicus and upper abdomen in previous surgery cases.
Procedures: Veress needle and 5 mm trocar and then telescope inserted from Jain Point. Under vision of 5 mm port from Jain Point, 10 mm port was optimized. Adhesions were noted in the umbilicus and upper abdomen and Jain Point was found consistently free of adhesions.
Results: 8103 cases were operated in a 10 years study period from Jan, 2011 to Jun, 2021. 2361 cases had previous one or more surgeries, either laparoscopy or laparotomy or a combination of both. There were no major vascular injuries, one bowel injury which was recognized and dealt by minilap in a case of frozen pelvis due to Koch’s abdomen. Minor complication like omental emphysema or pre peritoneal insufflation was seen in the initial learning curve, but did not cause bleeding or alter the course of present surgery.
Conclusions: Our study confirms the safety of Jain Point in previous surgery cases and also in situations where Palmer’s Point is contraindicated as this port is much lateral and lower down.
WHAT THE “F” IS IN THE LIFE OF A MINIMALLY INVASIVE SURGEON?
Objective: To highlight the importance of revisiting surgical principles for minimally invasive surgeons.
Methods and Results: Skill and experience in videolaparoscopy, meticulous knowledge of anatomy, utilization of proper instrumentation and knowledge of devices and energy are paramount in the surgical care of patients. These factors are of utmost significance and greatly influence surgical outcomes. These principles must not be overlooked and we must strive for their continuous teaching and implementation in order to train confident minimally invasive surgeons.
Conclusions: It is attention to detail and adherence to surgical principles that dictates safe and effective surgical outcomes. New generations of surgeons must return to these principles and implement them as the foundation of their practice. It is with implementing these principles that we can strive for improved outcomes and patient safety.
HOW MUCH IS ENOUGH? PERIOPERATIVE PAIN CONTROL AND OPIOID PRESCRIBING AFTER LAPAROSCOPY
Objectives: To review the background and prescribing practices in laparoscopic surgery.
Methods: Literature review.
Results: Currently in the United States and in many settings there is a crisis of opioid abuse and overdose deaths. Although the crisis is multifactorial, one major source of excess opioids is overprescribing in the postoperative period. Multiple studies have shown that patients typically use less than half of the opioids prescribed and that many patients feel that they are prescribed too many opioids. In addition to the risks of improper storage and disposal of excess opioids after surgery, there is the risk of new persistent use after perioperative opioid prescription, which may be as high as 6.8% after gynecologic surgery. More than half of the persons misusing prescription opioids obtained the pills from a friend. These issues must be considered when determining the need for opioid analgesia after surgery. At present, there is a wide variation in opioid prescription practices and no standard of care for pain control after minor laparoscopic surgery.
Conclusions: For most minor surgeries we propose that 0 – 5 tablets of opioid analgesia would be appropriate and that there should be an increased emphasis on nonopioid analgesics.
DEALING WITH PARAMETRIUM ENDOMETRIOSIS
Background: Endometriosis is characterized by the development of endometrial tissue outside the uterine cavity. Its main location is in the pelvic region, where it can affect the peritoneum, ovaries, uterosacral ligaments (LUS), bladder and bowel. Dysmenorrhea is the most common symptom. Other symptoms include dyspareunia, low back pain, dyschezia and dysuria (Mounsey, 2006).
Objective: To show how to approach parametrium endometriosis.
Methods and Procedures: Using videos and slides to show a step-by-step approach to improve the way parametrium endometriosis is treated.
Results: Using the systematization approach to parametrium endometriosis will help pelvic surgeons to enhance patient’s feedback.
Conclusion: Endometriosis has become one of the most challenging procedures in gynecology. Usually, we can find the disease infiltrating ureter, main vessels, nerves what makes necessary a very skilled pelvic surgeon. We will present some videos showing how to deal with this complex disease.
BEYOND ENDOMETRIOSIS: THE MANY GENERATORS OF PELVIC PAIN
Objectives: Endometriosis is a debilitating and enigmatic disease affecting more than 200 million worldwide. The disease may limit persons from participating fully in school, career, social settings, and parenthood. Many have pain persisting after complete excision of the disease. Avoiding repeat and unnecessary surgery is crucial when approaching quality of life in the person with endometriosis. Pain may be driven by many sources including but not limited to the pelvic floor, the bladder, and upregulation at the sacral nerve roots, hip joint pathology, and the pudendal nerve. The following presentation is an overview of multiple pain generators in the person with endometriosis.
Methods: A video overview of multiple pain generators in the person with endometriosis.
Conclusions: Pain post excision of endometriosis is often mistaken for more endometriosis or for surgical adhesions. All that ails the person with endometriosis is not endometriosis. Assumptions regarding endometriosis returning can often be wrong. Embracing evaluation for multiple generators of pain can help the patient immensely. Treating the direct source of pain leads to an increase in quality of life. Healing from endometriosis involves exploring all the generators of pain.
MULTIDISCIPLINARY APPROACH TO FIBROID AND ENDOMETRIOSIS MANAGEMENT
Objective: Describe development and implementation strategies for a multidisciplinary approach to fibroid, adenomyosis, endometriosis, and chronic pelvic pain management.
Methods and Procedures: Review disease-focused program development within a Minimally Invasive Gynecologic Surgical division in an academic hospital setting.
Results: A multidisciplinary approach towards complex gynecologic conditions leads to comprehensive patient care and improves collaboration between specialties.
Conclusions: Patients with fibroids, adenomyosis, endometriosis, and chronic pelvic pain should have access to multidisciplinary care and be thoroughly informed about all treatment options during a shared decision making process.
Video. IT’S IN THE BAG! A REVIEW OF LAPAROSCOPIC SPECIMEN RETRIEVAL
Elizabeth Miazga, Samantha Benlolo, Eliane Shore, Carmen McCaffrey, Andrea Simpson, Deborah Robertson, Sari Kives, Alysha Nensi
Objective: Choosing a laparoscopic specimen bag is a common decision point in gynecologic surgery. There is limited literature reviewing this topic. Laparoscopic bag selection can impact operative time, clinician frustration and health care costs.
Methods & Procedures: This video uses still images, video footage and narration to review available laparoscopic specimen bags. It discusses considerations in choosing a bag for different pathology and procedures and presents an approach to laparoscopic specimen retrieval. Video footage is used to present different techniques which can be used to avoid common problems and frustrations faced when using a laparoscopic bag.
Results: When planning a laparoscopic procedure involving specimen removal consider the type of scope used, port placement and the planned extraction site, the size and consistency of specimens and whether morcellation will be involved. These factors inform the size and type of laparoscopic specimen bag that will best fit the case. Bags can range in price from twenty to over two-hundred dollars, making knowledge of the prices important in a cost-conscious healthcare system.
Conclusion: There is a large variety of laparoscopic specimen bags available, each with specific advantages and disadvantages. Specimen size and pathology are the biggest factors when choosing an appropriate bag.
★ Carl J. Levinson Award for Best Video
Video. A STEPWISE APPROACH TO LEFORT COLPOCLEISIS
Samantha Benlolo, Elizabeth Miazga, Annette Epp, Alysha Nensi, Dana Soroka
Objective: The objective of this educational video is to describe the technique and required equipment for performing a LeFort partial colpocleisis using surgical footage as well as a low-cost surgical model.
Methods & Procedures: Using surgical footage and low-cost surgical model, we demonstrate a LeFort partial colpocleisis in six steps. (1) Proper patient positioning, (2) mark rectangular resection area, (3) dissect and resect vaginal epithelium, (4) place red rubber catheter to allow for lateral channels, (5) reduce prolapse using sequential pursestring sutures, (6) perineorrhaphy.
Results: N/A
Conclusion: Pelvic organ prolapse affects the quality of life of many patients, and one in nine will require corrective surgery by the age of 80. LeFort partial colpocleisis is a highly successful, minimally invasive surgical approach that is indicated in patients with pelvic organ prolapse who are no longer having vaginal intercourse and/or have comorbidities that prohibit a more extensive procedure. This video provides a stepwise approach to performing a LeFort partial colpocleisis.
★ Best Gynecology Video (1 of 2)
Video. ROBOTIC LAPAROSCOPIC ISTHMOCELE REPAIR IN EARLY PREGNANCY
Taralyn C. Sowby, Emery M. Salom
Objective: According to the CDC, Florida has a cesarean section rate of 38.6%. The marked increase in the rate of cesarean sections has created an emergence of associated complications. One such complication is an isthmocele, an outpouching of a uterine scar defect. One prospective Swedish study found that on ultrasound, 61% of patients that had one previous cesarean section had at least one visible uterine scar defect. There is currently minimal literature on the treatment of isthmocele (uterine scar defect) during pregnancy.
Methods & Procedures: Case Report
24yo F G3P1011 @ 12.2 weeks gestation with an isthmocele visible on ultrasound and MRI measuring 1.5 × 3.3 x 1.4 cm in the lower uterine segment superior to the internal os of the cervix and appearing separate from the amniotic sac and placenta. The patient has a history of one previous Cesarean section and one previous cesarean scar ectopic pregnancy that required laparoscopic hysterotomy, evacuation of ectopic products of conception, and laparoscopic repair of the prior isthmocele in layers. Prior to this procedure, the patient was counseled extensively on the risk of fetal loss secondary to the procedure. The patient was taken for a robotic laparoscopic repair of the isthmocele in order to decrease associated perinatal complications. The isthmocele and associated pseudosac were resected and the defect was repaired using PDS suture.
Results: Repeat ultrasound on POD#1 exhibited a viable intrauterine pregnancy with normal amniotic fluid.
Conclusion: With cesarean sections increasing, there will likely also be an increase in isthmoceles that will require surgical repair.
★ Best Gynecology Video (2 of 2)
Video. ROBOTIC-ASSISTED LAPAROSCOPIC RESECTION OF A CORNUAL ECTOPIC PREGNANCY
Alexandra I. Goodwin, Kaitlin Nicholson, Benjamin M. Schwartz
Description: This investigation discusses treatment of a cornual ectopic pregnancy using minimally invasive technique. We also explore the use of vasopressin as an adjunct in surgery to minimize blood loss. A cornual ectopic pregnancy is a pregnancy that implants in the cornua, the most proximal portion of the fallopian tube lying within the myometrium. Cornual ectopics comprise only 2–3% of cases of ectopic pregnancy, however, they have a significantly higher risk of maternal death, at 2–2.5%. This is a video case report of a 24-year-old G3P1011 at 7 weeks gestation who presented with severe left lower quadrant pain for 1 day. She was found to have a cornual ectopic pregnancy. The cornual ectopic was treated by robotic-assisted laparoscopy. Her treatment was further enhanced by the use of dilute vasopressin injected into the cervix and the cornua. The ectopic was dissected using monopolar scissors and removed from the uterus intact through an endocatch bag. The defect in the uterus was closed with a barbed suture. The entire procedure took approximately 50 minutes with an estimated blood loss of less than 10 cc. Postoperative course was uncomplicated with a normal bhCG at follow-up on postoperative day 27. Robotic-assisted laparoscopy is a safe and effective approach for resection of cornual ectopic pregnancies. Vasopressin can be used as an adjunct to minimize blood loss. Future research should continue to explore minimally invasive techniques for cornual ectopic resection, focusing on the use of adjunct procedures and medications to reduce surgical time and minimize blood loss.
Video. SURGICAL FIELD DEVELOPMENT FOR LAPAROSCOPIC HYSTERECTOMY: EXTRACORPOREAL SUSPENSION WITH STRAIGHT NEEDLE AND THREAD AND ITS PRACTICE IN DRY BOX
Objective: Quality of an operation depends largely on completeness of the developed surgical field. Suspension of any organ for the purpose of surgical field development is most effective when pulled from outside of a body. In this video, procedures and effectiveness of extracorporeal suspension of bladder and colon is demonstrated.
Methods: In total laparoscopic hysterectomy, dissected bladder peritoneum of vesicouterine pouch is suspended with straight needle and thread from outside of the body on three points at the beginning of an operation: bilateral dissected round ligaments and middle of the dissected bladder peritoneum. Fatty appendices of sigmoid colon are suspended in the same manner from outside of the upper abdomen.
Results: By extracorporeal suspension of bladder, loose connective tissue between bladder and uterine cervix is clearly recognized in linear fashion. Dislocation of bladder from uterine cervix made safer in every case. By extracorporeal suspension of colon, free space in cul-desac is created and manipulation in lt. pelvis made easier and safer.
Conclusions: Extracorporeal suspension of bladder and colon improve the quality of surgical field development drastically. Practice in dry box developed for extracorporeal suspension result in great help to master this method with straight needle and thread.
★ Honorable Mention – Best Gynecology Video
Video. SPACE ORIENTED APPROACH FOR LAPAROSCOPIC HYSTERECTOMY: NEW CONCEPT OF APPROACH TO PREVENT URETERAL COMPLICATION BASED ON CLINICAL PELVIC ANATOMY
Objective: Ureteral thermal damage is an important complication of hysterectomy. Blind electrocautery or electrocautery against hemorrhage from periureteral vessels is supposed as a major cause of this complication. New concept of a rearranged approach to retroperitoneal space based on clinical anatomy of pelvis is introduced as ‘space-oriented approach’ to prevent thermal damage of ureter in total laparoscopic hysterectomy.
Methods: In ‘space-oriented approach’, ureter is kept wrapped in subperitoneal fascia with its feeding vessels. Pararectal space of Latzko is the primary target to be developed. A space in lateral side of sacrouterine ligament is the other target to be developed. Ureter is dislocated from uterine cervix as a consequence. Randomly selected surgical video of 7 cases of total laparoscopic hysterectomy was compared to 7 cases of historical control on periureteral electrocauterization before and after colpotomy.
Results: Total sides of electrocautery attempted in 7 cases are decreased significantly in ‘space oriented approach’ before colpotomy (13/14 vs. 0/14, p = 0.000000748) and after colpotomy (9/14 vs. 0/14, p = 0.00058) compared to historical control.
Conclusion: ‘Space-oriented approach’ is an effective method to prevent ureteral thermal damage theoretically and clinically in total laparoscopic hysterectomy.
Scientific Paper. POST HYSTERECTOMY PARASITIC FIBROIDS AND ENDOMETRIOSIS
Amro Elfeky, David Herzog, Aaron Winnick
Objective: To describe a technique of management of parasitic fibroids and endometriosis posthysterectomy.
Methods, Procedures, and Results: We describe the surgical approach opted for the patient desiring surgical management for cyclical abdominal pain that started 4 years status post hysterectomy that was indicated for symptomatic fibroids. On repeated imaging, the patient was found to have an intrabdominal mass and two intramuscular masses below the umbilicus that were suggestive of endometriosis and parasitic fibroids. Furthermore, the patient needed surgical management of a symptomatic umbilical hernia. Upon laparoscopic examination intraoperatively, a 2 cm nodule was found attached to the mesentery of the transverse colon. The nodule was resected while avoiding injury to the underlying colon. The specimen was sent for a frozen section, which showed that the specimen was compatible with endometriosis and fibrous tissue. Below the umbilicus, a 4x2cm mass was found to be adherent to the anterior abdominal wall. The peritoneum was opened laterally and the mass was dissected off. The nodule appeared to invade the posterior fascia but did not invade the muscle layer. After the nodule was resected, closure of the fascial defect was attempted laparoscopically but was found to be under tension. Therefore, an abdominal counter incision was made and the fascia was reinforced. The patient was discharged in stable condition on the same day of surgery
Conclusion: Although benign, Parasitic Fibroids and Endometriotic implants are a possible complication after the use of electric morcellation and may warrant surgical resection of implants to improve symptoms and rule out abnormal pathology
Scientific Paper. 5 YEARS OF PERFORMING OFFICE HYSTEROSCOPY WITH A HAND-HELD DISPOSABLE CORDLESS DEVICE WITHOUT ANY ANESTHESIA: A RETROSPECTIVE REVIEW OF 600 CASES
Background and Objectives: Office Hysteroscopy is a popular acquisition for many Gyn practices especially in the USA. This handheld portable disposable device has made it possible to incorporate the procedure into regular office hours without special preparation or setup. Patient preparation is minimal and no anesthesia-not even local- is required.There were no complications. Entry into the uterine cavity was compromised in less than 1 per cent population.
Methods: 600 consecutive cases were selected from the author’s practice. Retrospective chart review was performed for age, parity, preexisting medical conditions, previous surgery, BMI, indications, size of uterus, existence of uterine pathology compromising entry and complications. The average time for the entire procedure was calculated. Comparison of pathology noted in office and eventual operative hysteroscopy procedure was done. Complications minor and major were documented.
Results: The office Hysteroscopy procedure with the comparatively new technology was found to be safe effective and extremely feasible for a Gyn practice. There were no major complications. Any difficult entry into the uterine cavity was abandoned. This happened in less than one percent. The average time for the procedure was 5 minutes.
Conclusion: Office Hysteroscopy is a safe and efficacious procedure which lends itself to regular office hours scheduling effectively. Complications are minimal and yield is great. A minimal challenge to set up was encountered. Eventual Operative Hysteroscopy revealed confirmatory findings and pathology. Office Hysteroscopy is a great tool for diagnosis and management of most Gyn conditions. It prevents the congestion in the Operating Room and time wasted between cases.
Video. ROBOTIC ASSISTED RESECTION OF PELVIC ENDOMETRIOID STROMAL TUMOR ARISING FROM ENDOMETRIOSIS
Objective: Malignant transformation of endometriosis is rarely seen with an occurrence rate of only 0.7–2% in all cases. The most common malignant transformation of endometriosis are endometrioid and clear cell adenocarcinoma. Most occur in the ovary with only 20% extragonadal including peritoneum, colon, rectovaginal septum and vagina. Endometriosis stromal tumors including adenocarcinoma arising from endometriosis can occur, although they are rare.
Methods & Procedures: This is a surgical case report involving a single patient. Wil review surgical technique for removal of the pelvic mass.
Results: Patient was followed 2 and 6 weeks postoperatively with no complication.
Conclusion: Rare occurrence extragonadal malignant transformation of endometriosis to Endometrioid Stromal Tumor with extensive smooth muscle differentiation which was successfully excised using the surgical robot.
Scientific Paper. MICROLAPAROSCOPIC METHOD FOR SELECTIVE APPENDECTOMY IN GYNECOLOGIC ENDOMETRIOSIS AND PELVIC PAIN SURGERY
Objective: We studied a strategy and technique for the liberal addition of adjunctive appendectomy in patients undergoing laparoscopic surgery for known or suspected endometriosis. Our surgical technique employs smaller “micro” or “low impact” trocars and instrumentation, including a 5 mm endoscopic stapling device. Our goal was to show support based on clinical and pathology findings, as well as the simplicity and safety of the procedure.
Methods and Procedures: A retrospective analysis was done on all patients that underwent appendectomy during gynecologic laparoscopic surgery at Sarasota Memorial Healthcare Systems during the study period. A low impact, microlaparoscopic technique was used with constant low pressure insufflation technology, a 5-8mm primary port, 3 mm accessory ports and 3-5mm instrumentation. The principles of ERAS enhanced recovery are employed including a low opioid strategy and local anesthetic/peripheral nerve injections. Evaluation included med usage, pain and satisfaction subjective scores and general postsurgical assessments.
Results: Twenty-six patients underwent conservative microlaparoscopy with adjunctive appendectomy based on clinical presentation or surgical findings. Pathology revealed cases of endometriosis, chronic or acute appendicitis, and two neuroendocrine tumors. We confirmed reliability and validity of the micro laparoscopic method using a 5 mm stapler. All patients had a normal postop course and no complications. Low analgesic usage and high satisfaction scores prevailed.
Conclusion: The American College of Obstetrics and Gynecology reaffirmed a Committee Opinion on Elective Coincidental Appendectomy in 2019. The use of a selective strategy for adjunctive “low impact” appendectomy is effective and can be used efficiently and safely.
★ Best Gynecology Scientific Paper
Scientific Paper. TRENDS IN INPATIENT ENDOMETRIOSIS MANAGEMENT IN NEW YORK STATE, 2009–2017
Adjoa A Bucknor, Lei A Qin, Susan Khalil
Objective: To assess trends in inpatient endometriosis care in New York State Hospitals between 2009 and 2017
Methods: Inpatient information from 2009 to 2017 was collected from the New York SPARCS database. The database was filtered for gender and ICD9 coding to identify inpatient admissions for endometriosis. Admission characteristics such as age, race, length of stay, and procedure codes were extracted. Categorical variables were compared using Pearson’s χ2 test.
Results: Majority of inpatient admissions occurred between the ages of 30 to 49 (N = 9882, 77.5). Most patients were identified as being white (N = 7711, 60.4%) and had private insurance (N= 2967, 23.3%). Patients in New York City comprised most admissions in the state (N = 5649, 44.3%). Mean length of stay for endometriosis-related admissions was 2.45 days. Most admissions (N = 5649, 90%) were for surgical intervention and the rest for medical reasons. Hysterectomies were the predominant procedure (N = 6898, 54%) followed by oophorectomies (N = 1254, 9.8%) and other procedures on the ovaries (N = 1159, 9.1%). The number of hysterectomies being performed for endometriosis has declined by 64% from 2009 to 2017.
Conclusion: We evaluated the trends in inpatient endometriosis care in New York State through analysis of the SPARCS database. We found that hysterectomy remains the most common procedure performed for endometriosis, but this number is declining. Furthermore, the number of inpatient admissions for endometriosis has been declining. We hypothesize that this may be due to both an increasing number of minimally invasive surgeons who offer specialized laparoscopic excision procedures as well as increased access to medical management.
★ Honorable Mention – Best Gynecology Scientific Paper
Video. FIRST REPORTED SINGLE-SITE LAPAROSCOPIC RADIOFREQUENCY ABLATION OF UTERINE FIBROIDS
Eesha Bhattacharyya, Olivia Manayan
Objective: Uterine leiomyomata are the most common benign tumors found in females. Due to their symptomatic manifestations, such as abnormal uterine bleeding, pelvic pain, and bladder/bowel dysfunction, they cause significant healthcare burden in the US. FDA approved in 2012, laparoscopic radio frequency ablation (Lap-RFA) of uterine fibroids has been shown to be an effective method of treatment for nonpedunculated fibroids <10cm. Lap-RFA has been shown to have lower rates of complications than both hysterectomy and myomectomy. Here, we present a novel approach to performing RFA using a single-site mode of entry. Laparoscopic Single Site surgery offers several advantages compared to conventional laparoscopic surgery, including improved cosmesis, decreased trocar-related visceral and vascular injury, and decreased postoperative wound infection and hernia formation. Additionally, single-site surgery has also been shown to have improved postoperative pain.
Methods/Procedures: Patient is a 29 year-old, G0 who presented with a three-year history of pelvic pain and abnormal bleeding. Ultrasound showed subserosal and submucosal fibroids. The patient chose to proceed with Lap-RFA. Using a laparoscopic ultrasound, 5 myomas were visualized and ablated with an RFA probe.
Results: The patient tolerated the procedure well and was discharged home that day. She returned for a postoperative visit 1 week later, where she reported improved pelvic pain and met al.l postoperative milestones.
Conclusion: In conclusion, today we present the first-reported case of a single-port laparoscopic radio frequency ablation of uterine fibroids. With this case, we show that it is a safe, feasible option for the treatment of fibroids.
Scientific Paper. EVALUATION OF A NOVEL UNIVERSAL ROBOTIC SURGERY VR-SIMULATION PROFICIENCY INDEX THAT WILL ALLOW COMPARISONS OF USERS ACROSS ANY VR CURRICULUM
Christopher Simmonds, Mark Brentnall, John P. Lenihan Jr
Study Objective: Calculate a universal proficiency metric for Robotic Surgery VR simulation that will allow comparison of all users using any VR curriculum.
Materials and Methods: Mean scores for each exercise in over 600,000 sessions using Mimic simulation exercises were calculated . Those Mean scores were then normalized to 100. Subject’s scores were also averaged and normalized to 100. We called this Index score the MLearn Proficiency Index (MPI). Scores above 100 were better than average; Less than 100 were worse than average. This produces a single user proficiency index for each exercise.
Measurements and Main Results: 17,648 sessions from two training institutions were analyzed (2017–2020) comparing 77 students (residents to practicing surgeons) working in 7 different curriculums. The MPI mean score for all participants in all curricula was an MPI of 104.9 (SD: 15.5). 13 students were more than 1 standard deviation below the norm with an average MPI of 80.15. This group averaged 9 hours 27 minutes each on the simulator attempting 23.46 exercises but becoming proficient in only 10.38 (47%) of them in 224 sessions. 12 student’s scores were greater than 1 standard deviation above the norm with an average MPI of 127.05. This group averaged 6 hours 31 minutes each on the simulator attempting 29.08 exercises and becoming proficient in 27.5 (95%) of them in 196 sessions.
Conclusions: A universal skill-based proficiency index (MPIÓ) was found to be a reliable tool that could be used to identify relative proficiency among students in different robotic surgery VR Simulation curriculums.
Scientific Paper. INITIAL EXPERIENCE OF ROBOT-ASSISTED BREAST CONSERVING SURGERY
Objective: A traditional breast conserving surgery operation inevitably results in an external scar on breast. Robot-assisted surgery has been successfully and reproducibly performed for mastectomy. We performed a robot-assisted breast conserving surgery through axillary incision to obtain good postoperative and excellent cosmetic outcomes.
Methods and Procedures: A 43-year-old woman and a 52-year-woman with breast cancer were selected. All surgical procedures were performed in concordance with the traditional breast conserving operation.
Results: All procedures were technically successful with no skin incisions on the breast. The total operation time was 180 and 140 minutes and the total blood loss was 100 and 80 mL, respectively. The operative scars in axilla became inconspicuous in a few weeks.
Conclusion: Robot-assisted breast conserving surgery is technically feasible, safe, and effective. This new technique can be a good alternative surgical option, particularly for young female patients.
★ Best General Surgery Scientific Paper
Scientific Paper. THE CURRENT USE OF ROBOTIC SURGERY IN GYNECOLOGY IN ONTARIO – A SURVEY
Samantha Benlolo, Alysha Nensi, Andrea Simpson, Sari Kives, Filomena Meffe, Deborah Robertson
Objective: To determine the present state of robotic gynecologic surgery in Ontario, by assessing the number and characteristics of robotic surgeons, patient selection process, funding sources, volume of cases and perspectives on its use.
Methods & Procedures: From Mar to Oct 2020, electronic questionnaires were distributed to departmental chiefs of Obstetrics and Gynecology at the 10 academic and community hospitals in Ontario identified as having a surgical robot. Department chiefs were asked to distribute a self-administered electronic survey to robotic gynecologic surgeons at their institution to capture individual practice and perspective data.
Results: Responses were obtained from 10/10 (100%) department chiefs, and 14/19 (73.7%) robotic surgeons. Seven of the 10 sites use the robot for gynecologic surgery. The majority have been using the robot for ≥8 years (57.1%, n = 4) with annual case volumes of 30–100. Most respondents have subspecialty training in minimally invasive surgery (42.9%, n = 6) or gynecologic oncology (50%, n = 7). Indications for a robotic approach included hysterectomy for endometrial cancer/hyperplasia in patients with an elevated body mass index (BMI) (93%,n = 13), myomectomy (43%, n = 6), endometriosis (14.3%, n = 2) and ovarian cancer (7%, n = 1). Funding sources included private donors (42.9%, n = 6), hospital foundation (57.1%, n = 8) and hospital administration (28.6%, n = 4). Most respondents (92.3%, n = 12) believed that robotic surgery should be more widely available.
Conclusions: Robotic gynecologic surgery in Ontario is performed at seven hospitals by 19 surgeons. The most common indication for a robotic approach is hysterectomy for endometrial cancer/hyperplasia in patients with an elevated BMI. Ongoing governmental financial support is necessary to ensure equitable access to care in this complex population.
Video. SINGLE PORT ROBOTIC ASSISTED LAPAROSCOPIC SACROCOLPOPEXY: NEW FRONTIER IN MINIMALLY INVASIVE ABDOMINAL REPAIR OF PELVIC ORGAN PROLAPSE
Sofia Ahsanuddin, Mubashir Billah, Salma Ahsanuddin, Joshua Cadwell, Mutahar Ahmed
Objective: In 2019, the FDA ceased the distribution of transvaginal mesh which solidified robotic sacrocolpopexy as the standard surgical approach to repair complete pelvic organ prolapse. In 2018 a single port robotic system came to market. In this study, we aim to assess the feasibility of using this new single port system in robotic sacrocolpopexy.
Methods: We conducted a retrospective review of all single port robotic sacrocolpopexies performed at a single institution by a single surgeon. Perioperative data and follow-up data were collected and reviewed.
Results: Two patients had undergone robotic sacrocolpopexy with hysterectomy for stage 4 pelvic organ prolapse. Average total operative time was 125 minutes including time for hysterectomy with average estimated blood loss of 50 milliliters. Both patients were discharged on postoperative day 1 with no perioperative complications including but not limited to bowel related complications. At 3- and 6-month follow-up visit, both patients had complete resolution of their prolapse with no associated incontinence or voiding symptoms. Both patients reported ability to resume normal sexual function.
Conclusions: Our review demonstrates that single port sacrocolpopexy is a feasible and reproducible alternative to multiport sacrcolpopexy. With fewer incisions, single port surgery potentially enables less postoperative pain and improved cosmesis. Single port surgery has an associated learning curve and limitations that warrant further evaluation. We observed that the single port system is better suited for small to medium size uteruses given the limited grip and movement strength of the single port instruments. Further comparison to multiport sacrcolpopexy is ongoing at our institution.
THE USE OF ROBOTIC SURGERY IN THE MANAGEMENT OF DEEP INFILTRATING ENDOMETRIOSIS
Endometriosis is a condition that affects at least 1 in 10 women worldwide and is a common cause of Dysmenorrhea, Dyspareunia, Dyschezia, and Chronic Pelvic Pain. Endometriomas affect more than 20% of women with endometriosis and are often associated with deep infiltrating endometriosis in 60%–60% of women that present with Endometriomas. Management of endometriomas and associated Deep infiltrating endometriosis is extremely important because of all types of endometriosis are most likely to affect the fertility of a patient. The presence of endometriomas can cause decreased ovarian reserve and affect e.g., quality and implantation rates. Deep Infiltrating Endometriosis can cause many of the symptoms of endometriosis including Dyschyzia, Dyspareunia, Chronic pelvic pain, GI and GU symptoms often in very young women. Excision of DIE lesions in a conservative yet complete method is extremely important in treatment of these issues while maintaining fertility. Associated endometriomas must also be removed in a method that does not decrease ovarian reserve but prevents recurrence. Robotic surgery had increased the precision of complex surgery and extended the ability of surgeons to perform these surgeries worldwide. CO2 laser has also added and energy tool that increases precision of cut but decreases thermal spread and damage to nearby tissues. Utilizing these tools in synergy is enhancing our ability as minimally invasive surgeons to effectively treat Endometriomsas and DIE surgically. This presentation will review the diagnosis and management of endometriomas iand DIE including mechanisms to identify patients that may benefit from surgical management as well as advanced techniques that a surgeon may use to adequately excise lesions with minimal tissue damage. A discussion of tips and techniques of addressing both the endometrioma as well as the associated endometriosis will be held. Surgical techniques and types of energy used to treat endometriosis surgically will also be reviewed.
TECHNOLOGY ASSISTED SURGERY IN 2021 AND MOVING FORWARD IN UROLOGY
Objective: To provide an update on advances in robotic surgery in 2021.
Methods: The literature was reviewed for advances in robotics in urology.
Procedures: Those technologies and techniques that seemed most impactful were reviewed in this presentation.
Results: There have been several techniques utilizing technology assisted surgery that have been developed and are improving clinical outcomes in urology. Those include transgender and complex reconstructive cases, retzius sparing prostatectomy, inguinal lymphadenectomy, and renal transplant (recipient). There is also advancing technology in the area of robotic ureteroscopy. These approaches, clinical outcomes, and technologies are described in the presentation.
Conclusions: There have been several approaches and techniques developed recently in urology that show great potential for growth and impact using technology assisted surgery now and moving forward. There are also rapid improvements in some of the technologies in robotic surgery that are moving the ball forward for our patient’s outcomes.
SINGLE PORT ROBOTIC SURGERY: NOVEL APPLICATIONS FOR GYN SURGERY
Objectives:
• Introduce the novel platform for Single Port Robotic Surgery.
• Demonstrate early cases and application in GYN surgery.
• Review early outcomes and potential future applications.
Methods: Tips and tricks to adopting the new single port robotic platform for gynecologic surgery. Early experience and results are presented along with techniques for docking and performing pelvic surgery.
Results: Single port robotic surgery allows for the benefits of robotic surgery, including 3D visualization and instrument articulation, to perform gynecologic surgery safely. Surgical times appear to be comparable to other minimally invasive modalities. This modality is feasible for same day discharge as demonstrated by early clinical outcomes.
Conclusions: Single port robotic surgery is safe and effective for gynecologic surgery. Clinical outcomes require further evaluation and comparative trials, but early experience shows safety and comparable operative time to other minimally invasive modalities.
Scientific Paper. BURNOUT AMONG MINIMALLY INVASIVE SURGEONS PRIOR TO COVID-19: RESULTS FROM A MULTISPECIALTY SURVEY OF THE SOCIETY OF LAPAROSCOPIC & ROBOTIC SURGEONS
Sujan Munver, Bethany Desroches, Nermarie Velazquez, Ravi Munver
Objective: Physician burnout is increasingly observed among surgeons performing minimally invasive surgery (MIS). The purpose of this study was to assess multispecialty awareness and effect of burnout within members of the Society of Laparoscopic & Robotic Surgeons (SLS) prior to COVID-19.
Methods & Procedures: An anonymous 16-question survey was conducted among members of the SLS, assessing demographics, understanding, prevalence, and impact of physician burnout within this surgical group.
Results: Surveys were sent to 1301 members, and received by 1126 members of the SLS. Of the responses, 98% were physicians, and all surgical subspecialties were represented. Laparoscopy (61%) and robotics (22%) were the most common surgical techniques. Less than 8% of respondents denied physician burnout, with 21% endorsing “often”, 39% “sometimes,” and 30% “rarely” experiencing burnout. Participants described emotional exhaustion (73%), physical manifestations (58%), and depersonalization (53%). A total of 58.8% stated clinical performance was not affected, while >66% endorsed administrative demands and electronic documentation as causes for burnout
Conclusion: This is the first physician burnout study to focus on multispecialty laparoscopic and robotic surgeons within a MIS society. Minimally invasive surgeons are most affected in the realms of physical and emotional exhaustion, but all areas of the life were affected. Most physicians did not believe burnout affected their clinical performance. Although 39% stated there was no solution for burnout prevention, 40% provided optional explanations for potential solutions to physician burnout. This study reveals that most minimally invasive surgeons across specialties experience burnout, which significantly impacts their quality of life.
★ Paul Alan Wetter Award for Best Multispecialty Scientific Paper
Scientific Paper. ARTICULATED LAPAROSCOPIC INSTRUMENTS EMULATING ROBOTIC FEATURES: A LEARNING CURVE ANALYSIS
Juan A Sánchez-Margallo, David Durán Rey, Francisco M. Sánchez-Margallo
Objective: To present the analysis of the surgeon’s surgical performance and workload using a new design of articulated mechanical instruments for laparoscopic surgery that emulates features of surgical robots.
Methods & Procedures: Two laparoscopic articulated instruments, a grasping forceps and a Maryland dissector, with 5 mm of diameter and an articulated tip that allows up to 90 degrees of flexion in any direction and 360 degrees of rotation have been used in this study. Six novice laparoscopic surgeons performed several coordination tasks, and a dissection task and intracorporeal sutures in organic tissue. Each task was repeated five times. For each task, the surgeon’s learning curve in surgical performance and workload (SURG-TLX) were assessed.
Results: The surgeons showed an evolution in performance in the tasks of passing the needle through a ring circuit (562.0 ± 64.338 vs 413.8 ± 148.093 s; p < .05), dissection (375.333 ± 187.126 vs 203.015 ± 119.528 s; p < .05) and suturing (375.045 ± 123.016 vs 191.667 ± 49.127 s; p < .05). A significant reduction in the number of errors was obtained during the transfer task (9.8 ± 2.949 vs 3.2 ± 1.095 errors; p < .05). The level of surgical workload experienced by the surgeons decreased significantly after the training period, mainly in mental and temporal demand, task complexity and stress experienced (p < .05).
Conclusion: Preliminary results with the new laparoscopic instrument design show a positive learning curve with respect to surgical performance. Training with the new instruments leads to a reduction in the workload experienced by the surgeon and in the number of errors made during laparoscopic practice.
Scientific Paper. SAFETY AND FEASIBILITY OF COMBINED MINIMALLY INVASIVE GYNECOLOGIC AND GENERAL SURGERY
Katherine A Kleinberg, J. Salvador Saldivar, Benjamin Clapp
Introduction: There are many instances when a patient can undergo a combined general surgery operation with a gynecologic procedure. This is more convenient for the patient and only involves one anesthetic event. We present a case series of combined minimally invasive gynecologic and general surgery procedures and examine surgical outcomes and postoperative morbidity.
Methods: This is a retrospective study looking at a series of nine cases from one gynecologist and three general surgeons from 2013–2019. Cholecystectomy was performed either laparoscopically or robotically. Gynecological procedures included robotic hysterectomy, bilateral or unilateral salpingo-oophorectomy, lymphadenectomy, or a combination. Data regarding demographics, surgical details, hospital stay, and postoperative complications were recorded.
Results: Four (44%) of the cholecystectomies were performed robotically vs. laparoscopically while all of the gynecologic procedures (100%) were completed using the robot. None of the cases necessitated conversion to laparotomy. Depending on the general surgeon, between five and six surgical ports were utilized. Median surgery time and estimated blood loss (EBL) were 135 minutes and 89 mL respectively. Average hospital stay was 22 hours. Only one patient (11%) with cirrhosis encountered a postoperative readmission on postoperative day 26 for urosepsis.
Conclusion: Combined minimally invasive gynecologic and general surgery is a safe and feasible alternative to two separate surgeries. Concurrent surgery yields minimized healthcare costs and time under anesthesia while providing a low risk of postoperative morbidity.
Video. LAPAROSCOPIC MANAGEMENT OF PERFORATED INTRA-UTERINE DEVICE EMBEDDED IN THE SIGMOID COLON
Golnaz Namazi, Thomas C Tsai, Louis P King
Objective: The objective of this video is to demonstrate laparoscopic removal of perforated copper intra-uterine device (IUD) from sigmoid colon wall.
Methods & Procedures: This case was performed in an academic tertiary medical center. We started with a diagnostic hysteroscopy given the pelvic X-ray findings. We proceeded to diagnostic laparoscopy showing sigmoid colon involvement. After a flexible sigmoidoscopy showing no colonic perforation, IUD was removed laparoscopically.
Results: The copper IUD was successfully retrieved from the sigmoid colon.
Conclusion: Laparoscopic retrieval of an intra-peritoneal IUD is a safe and preferred first line of treatment.
★ Best Multispecialty Video
Scientific Paper. MINIMALLY INVASIVE PERCUTANEOUS PERIPHERAL NERVE STIMULATION FOR RELIEF OF CHRONIC KNEE PAIN
Objective: A 45-year-old woman presented with chronic right knee pain due to a history of meniscal tears and degenerative joint disease. Limitations included ADLs as well as caring for her children. Treatment options such as NSAIDs, physical therapy, steroid and high molecular weight hyaluronic acid injection did not provide sustained relief.
Nerve block of the femoral, saphenous and tibial genicular nerves did give relief for the duration of the local anesthetic used. The patient’s young age disqualified her from knee replacement surgery, and she did not want an implanted pulse generator, so peripheral nerve stimulation with a wearable antenna was chosen.
Methods: Patient first underwent percutaneous peripheral nerve stimulation trial of the superomedial and inferomedial genicular nerves under fluoroscopic guidance. She reported over 70% symptom relief during the trial phase, with maximal relief in isolated targeting of the superomedial branch.
A minimally invasive system was implanted for the superomedial genicular nerve under fluoroscopic guidance. The neurostimulator was placed using the vendor deployment needle so the electrodes were laying longitudinally along the nerve based on anatomic position. A 1.5 cm incision was made to coil the neurostimulator and the system receiver under the skin.
Result: By using the vendor’s wearable antennae assembly, patient has been able to achieve sustained 50% relief for over 2 years.
Conclusion: Percutaneous peripheral nerve stimulation is a treatment option for refractory knee pain. This case presents a minimally invasive approach that utilizes a small receiver rather than an implantable pulse generator, providing the patient with sustained relief.
Scientific Paper. MINIMALLY INVASIVE SURGERY TRAINING USING TRADITIONAL KOREAN CULINARY ART
Michael Dennis Isaias Dela Paz
Objective: Surgical skills training from open procedure to laparoscopic procedure up until to robotics procedure comes with certain uniqueness that a surgeon should need to master. In order to shift gear for all the technique to compliments each other, a slight break should be applied and that’s how Korean surgeon enjoyed their training - by having a break of eating out together with the whole training staff composed of both the mentor and the menthe after a tiring day. In this technical note, we harness culinary art in order to find an exciting way of minimally invasive surgery training during break time.
Methods and Procedures: One of their culinary tradition is grilling samgyeopsal or pork belly strip which is the use of this technique: to apply samgyeosal cooking in laparoscopic box training. It requires modified laparoscopic box or dome trainer applied to a Korean barbecue grill wherein the procedure involves cooking or grilling pork belly strip with the use of laparoscopic instruments such as grasper, dissector and scissors.
Results: Same as the standard laparoscopic box exercises, it exercises hand-eye coordination, depth perception, spatial coordination, instrumental tactile feedback, tissue handling skills and nondominant hand skills of both the surgeon-cook and his or her assistants. The end product of this exercise is a sumptuous delicious Korea barbecue food which could be eaten and enjoyed by the team
Conclusion: Laparoscopic samgyeopsal cooking is a feasible alternative minimally invasive surgery skill exercise training that can supplement standard modern virtual simulated laparoscopic training.
Scientific Paper. DISSEMINATION OF MEDICAL RESEARCH OUTPUTS IN TIMES OF PANDEMIC
Calin I Tiu, Francisco M Sanchez-Margallo, Patricia Sánchez-González, Octavia Medge, Alexandru Negoita Tiu, Vlad Eugen Tiu, Juan Alberto Sanchez-Margallo
Objective: The aim of this study is to explore methods recently used for the dissemination of research results from medical education projects during the COVID-19 pandemic and to propose new ways of research dissemination adapted to periods of medical crisis.
Methods & Procedures: An analysis of the dissemination activities already done or planned for the future period was conducted in the context of different research projects by the members of a research team based in Romania.
Results: Alternative methods of disseminating research output were explored. During online scientific events such as national and international conferences and congresses members of the research team were available to present the results obtained so far in different technology-based research projects and discuss them with healthcare. Contact with medical professionals by e-mail was another effective method which helped to report on progress in research activities carried out at European level by mixed teams and to disseminate relevant results.
Conclusion: New ways of disseminating the research results of in the field of medical education adapted for the special conditions experienced by the medical and scientific community during 2020 proved to be efficient and even better in terms of reaching more professionals and are considered for future use even under normal conditions. These results will be applied to the dissemination activities of new projects recently initiated such as the Mixed Reality in Medical Education based on Interactive Applications (MIREIA) project.
Video. TECHNICAL APPROACH FOR ROBOTIC-ASSISTED STAGING AND OPTIMAL CYTOREDUCTION OF LOCALLY ADVANCED ENDOMETRIAL CANCER
Objective: This video demonstrates surgical techniques that can be utilized to optimally cytoreduced locally advanced endometrial cancer via a robotic approach
Methodology: The patient received neoadjuvant chemotherapy. Preoperative CT scan indicated omental caking with involvement of the pelvic peritoneum and uterosacral ligaments. The patient had diagnostic laparoscopy which showed disease limited to the pelvis. Robotic surgical techniques demonstrated include 1) upfront vascular control of pedicles, 2) lateral mobilization of ureters for management of uterosacral disease, 3) peritonectomy for excision of peritoneal lesions, and 4) infracollic omentectomy.
Results: The patient was debulked to zero residual disease. She was discharged the following day and had no postoperative complications. She received a shortened course of postoperative chemotherapy with carboplatin and paclitaxel due to noncompliance and recurred in the pelvis one year later.
Conclusion: A robotic approach for staging and complete cytoreduction of locally advanced endometrial cancer is feasible with good postoperative and oncological outcome.
★ Honorable Mention – Best Gynecology Video
Scientific Paper. SENTINEL LYMPH NODE BIOPSY WITH INDOCYANINE GREEN IN ENDOMETRIAL CANCER PATIENTS – PRELIMINARY RESULTS
Slavcho Tomov Tomov, Grigor Angelov Gorchev, Aleksandar Dimitrov Lyubenov, Dimitar Georgiev Dimitrov, Georgi Danielov Prandzhev
Objective: The performance of lymph node dissection in early stage endometrial carcinoma is still under discussion. The aim of this study is to present preliminary data of sentinel lymph nodes identification after application of indocyanine green (ICG) in the cervix of patients with endometrial cancer.
Methods & Procedures: Fourteen patients with histologically proven endometrial carcinoma T1 stage have undergone robot-assisted total hysterectomy. The lymph mapping was performed with the introduction of ICG with the assistance of fluorescence imaging technology of the surgical robotic system. After detection of the lymph chains and regional sentinel nodes, biopsy have been performed, evaluated with frozen section.
Results: Sentinel lymph nodes were detected in 13 (92%) patients, both-sided – in 8 (57%) and one-sided - in 5 (35%) of them. In only one case no sentinel lymph nodes have been visualized. Metastases in the lymph nodes were not detected in any of the patients.
Conclusion: The application of ICG for identification of sentinel nodes in early-stage endometrial cancer is safe and effective method for assessment of regional lymph node basin. However, additional data are required to assess its oncological significance.
Video. INITIAL SURGICAL MANAGEMENT OF BULKY MALIGNANT MIXED MULLERIAN TUMORS OF THE ENDOMETRIUM BY A ROBOTIC APPROACH
Gerald A Feuer, Idine Mousavi, Nisha Lakhi
Objective: Malignant Mixed Mullerian Tumors (MMMT) often present with very large, necrotic tumor burden in the uterus that leads to dilation and effacement of the cervix. In patients with this presentation, conventional hysterectomy poses a much greater challenge as the ureters are laterally deviated and compressed by the tumor, and thus are at an increased risk for injury. Given this surgical challenge, many of these patients may begin with neoadjuvant chemoradiation. However, these treatment modalities are associated with significant toxicity and may impact patient quality of life. Therefore, we present a minimally invasive robotic surgical approach that aims to optimize quality of life without sacrificing prognosis.
Methodology: The patient had biopsy proven MMMT. Preoperative CT scan showed an enlarged uterus with no evidence of extrauterine disease. On presentation, the cervix was dilated and effaced with extruding disease. Disease was initially reduced transvaginally immediately prior to placement of the uterine manipulator using a ring forceps to extract tumor. Robotic approach included 1) upfront vascular control of pedicles, 2) radical hysterectomy with complete dissection of the ureters secondary to the dilated and effaced cervix, 3) infracollic omentectomy, 4) lymph node dissection, and 5) appendectomy.
Results: The patient was debulked to zero residual disease. She was discharged the following day and had no postoperative complications.
Conclusions: A robotic approach for staging and complete cytoreduction of bulky Malignant Mixed Mullerian Tumors is feasible with good postoperative outcome.
Video. TRANSVERSE MESOCOLIC INTERNAL HERNIA AS A RARE CAUSE OF SMALL BOWEL OBSTRUCTION IN A VIRGIN ABDOMEN: DIAGNOSIS, MANAGEMENT AND LAPAROSCOPIC REPAIR
Alexandra I Over, Nicholas Champion, Diego Monasterio Oliver, Lisa Shimotake, Karen E Gibbs, Indraneil Mukherjee
Objective: Demonstration of Diagnosis, Management, and Laparoscopic Repair of Transverse Mesocolic Internal Hernia.
Methods & Procedures: A 28-year-old female with no past medical or surgical history presented to our emergency department with vomiting and severe epigastric pain increasing in intensity for the last 8 hours. There were no clinical signs of peritonitis– vitals and labs were within normal limits. CT-Scan was concerning for closed loop bowel obstruction. She was taken for urgent exploratory laparoscopy. On initial examination we saw dilated bowel in the left upper abdomen going into a small defect at the base of the transverse colon mesentery in the right upper quadrant. Three feet of small bowel were reduced from the supracolic space and the defect was closed primarily.
Results: She was discharged 5 hours later. On outpatient follow up 12 days later, patient reported to be completely asymptomatic.
Conclusion: Internal hernias are a rare and dangerous cause of small bowel obstruction that are difficult to diagnose because of their nonspecific clinical presentation and CT findings, as well as their anatomical variety, especially in virgin abdomens. This report describes a case of a particularly rare internal hernia through the transverse mesocolon. Patients presenting with small bowel obstruction should be expeditiously considered for the presence of internal hernia regardless of surgical history, as nonoperative management in these cases can lead to bowel ischemia and significant morbidity. Laparoscopic exploration and repair should include inspection of common congenital hernia locations including para-duodenal, peri-cecal, Foramen of Winslow and transmesocolic.
★ Best General Surgery Video
Scientific Paper. “SLIM-MESH”: 11-YEAR FOLLOW-UP STUDY ON MID-TERM RESULTS IN 43 CASES OF LARGE-GIANT/MASSIVE VENTRAL HERNIA
Silvio Alen Canton, Claudio Pasquali
Objective: We devised a sutureless “Slim-Mesh” technique to treat ventral hernias, including large-giant/massive ones, reduce intra- and postoperative complications, and lower operative time.
Methods & Procedures: Between Sep 2009 and Oct 2020, 43 patients with large (10–15 cm)-giant (15–20 cm)/massive (≥20 cm) ventral hernia were operated at our Department with the above technique. This was a prospective (79%)-retrospective study
Results: This study comprised 22 males and 21 females. Mean age was 63 years. Large-giant and massive hernias were found intraoperatively in 37 and 6 cases respectively. Mean operative time for all hernias was 116 minutes, 104 for large-giant hernias, and 190 for massive. In 53.4% of cases, hernia-neck operative measurement was larger than preoperative size. In 25.5% of cases laparoscopy found satellite hernias previously undetected by US and/or CT-scan. A composite mesh and a noncomposite mesh were used in 95% and 5% of cases respectively. For mesh fixation, titanium tacks and absorbable straps were used in 14% and 86% of cases respectively. Mean length of hospital stay was 2.3 days. Mean follow-up time was 3 years and 4 months. In our study, there were 5 early postoperative complications: 3 seromas, 1 trocar-site hernia, and 1 case of cystitis. We found 2 late small (<2 cm) symptomless recurrences (4.6)
Conclusion: The sutureless “Slim-Mesh” technique facilitates intra-abdominal introduction, as well as the handling and fixation of giant and monster (36 × 26 cm) meshes. In our experience, “Slim-Mesh” is safe, simple, fast, and economical even for large-giant/massive ventral hernia repair.
★ Honorable Mention – Best General Surgery Scientific Paper
Scientific Paper. CRUROPLASTY REINFORCEMENT DURING ROBOTIC FUNDOPLICATION FOR LARGE PARAESOPHAGEAL HERNIA
Massimo Arcerito, Harpreet Kaur, John T Moon
Objective: Large paraesophageal hernias represent a surgical challenge with high recurrence rate applying minimally invasive techniques. We hypothesized the use of biosynthetic mesh in reinforcing the cruroplasty is an adjuvant technique to robotic fundoplication in large paraesophageal hernias.
Material and Methods: One hundred patients (67 females), mean age 66 year old (22–92) and large paraesophageal hernias, by radiographic criteria, underwent robotic fundoplication with biosynthetic tissue reinforcement mesh. Emergent surgery, operative time, intra- and perioperative complications, hospital stay, short and long clinical outcome, postoperative dysphagia and mesh related complications represented main outcome measures.
Results: Twelve patients presented with acute onset of symptoms. Three gastric perforations were repaired robotically. Mean hospital length was 36 hours (24–96). Eight patients experienced dysphagia. One patient required multiple dilations with resolution of dysphagia. Eight patients (8%) recurred by radiographic criteria. Five were symptomatic and underwent attempted robotic REDO fundoplication and gastropexy, with three conversions. The use of the biosynthetic mesh made the REDO fundoplication very challenge, but doable. No mesh complications were observed at median clinical follow up of 43 months (6–74).
Conclusions: Robotic fundoplication with biosynthetic mesh reinforcement provides a successful methodology in treating large paraesophageal hernias. Based on the low incident of hernia recurrence, the use of biosynthetic mesh leads to excellent clinical outcome. In recurred patients, the use of biosynthetic mesh creates a challenging REDO fundoplication. The high dexterity of robotic surgery helps to replicate the minimally invasive principles in the fundoplication technique, achieving the best outcome for the patient.
★ Honorable Mention – Best General Surgery Scientific Paper
Video. LAPAROSCOPIC EXTRA PERITONEAL ABDOMINAL WALL RECONSTRUCTION FOR RECURRENT VENTRAL HERNIA
Rayna M. Walburger, Nisha Narula, Karen E. Gibbs, Lisa Y. Shimotake, Indraneil Mukherjee
Objective: Demonstration of Complex Abdominal Wall Reconstruction for Recurrent ventral hernia done laparoscopically.
Methods & Procedures: 80-year-old male who had previously undergone two open midline hernia repairs, one with mesh. He presented to the office complaining of recurrence of hernia which increased in size with coughing and standing. The patient was taken for a laparoscopic extraperitoneal ventral hernia repair with mesh placement in the retrorectus plane. The Left Retro Rectus space was entered with an optical trocar. Dissection was continued in this plane to insert two more trocars. Another optical trocar was then inserted on the right retro rectus space and another trocar was placed in the space. A light was followed to open the space between the two sides. The whole hernia sac was dissected along with the previous mesh to join both the right and the left retrorectus plane. The hernia defect was closed, by approximating the anterior rectus sheaths with barbed absorbable sutures. A polypropylene Mesh was then inserted into this common space. The trocar sites were closed.
Results: The patient was discharged from the postoperative recovery room. He had an uneventful recovery.
Conclusion: Complex Abdominal Wall Reconstruction can be done safely as ambulatory surgery in debilitated patients using Minimally invasive techniques.
Video. BLADDER INJURY REPAIR WITH BARBED SUTURES
Omar F Duenas Garcia, Megan Stemple, Alec Sunyec, Robert E Shapiro
Objective: In this video our purpose is to demonstrate the use of a barbed sutures to perform an bladder injury repair.
Materials and Methods: We used a 0 barbed suture to repair an incidental bladder injury during a robotic assisted laparoscopic sacral colpopexy. This patient had a history of a hysterectomy and the bladder was adherent to the vaginal wall, and it was difficult to be dissected away. The bladder was injured and repaired in two layers. We also performed a retrospective chart review of our institutional experience.
Results: Sixty-eight patients were identified with iatrogenic cystotomy at our institution. Barbed suture was used for cystotomy repair in 11/68 (16.2%) patients. No significant difference was seen in postoperative outcomes between patients repaired with barbed suture versus standard braided suture. Barbed suture was significantly more likely to be used for cystotomy repair in minimally invasive surgery (p = 0.001). It was most often utilized in a robotic approach 7/11 (63.6%) followed by laparoscopic 3/11 (27.3%). Body mass index was significantly higher in patients receiving a barbed suture repair (p = 0.005).
Conclusion: Barbed suture is not inferior to standard braided suture for cystotomy repair and does not cause an increase in complication rate. Barbed suture offers a practical alternative to facilitate cystotomy repair in minimally invasive surgery.
★ Honorable Mention – Best Multispecialty Video
Video. ROBOT ASSISTED PARTIAL CYSTECTOMY FOR BLADDER ENDOMETRIOSIS – DUAL APPROACH INVOLVING CYSTOSCOPY AND ROBOTIC SURGERY
Anupama Bahadur, Rajlaxmi Mundhra, Sunil Kumar Chaurasia, Poonam Sherwani, Dhriti Kapoor, Shalinee Rao
Objective: Bladder endometriosis (BE) is characterised by presence of endometrial glands and stroma in detrusor muscle; trigone and dome being the most common sites. Bladder is the most frequent type of urinary tract endometriosis seen in almost 70–85% cases, followed by involvement of ureters in nearly 9–23% of urinary tract endometriosis cases.
Methods & Procedures: 34 year old P2L2 with previous two caesarean deliveries presented with chronic pelvic pain & cyclical hematuria for last two years. Ultrasonography showed focal irregular thickening of 26 × 16 mm in posterior wall of urinary bladder in midline. Records of cystoscopy showed 3 × 2 cm endometriotic spots in posterior wall of bladder around 2cms away from left vesicoureteric orifice. MRI confirmed bladder endometriosis. Herein, we describe a dual surgical approach wherein the margins of the endometriotic spot were delineated and cut using cystoscopy followed by robotic approach to completely excise the nodule along with bladder repair.
Results: Presence of cyclical haematuria along with tender anterior vaginal wall should alert the gynaecologist or urologist to consider this rare entity. Treatment is medical therapy followed by surgery when needed. Transurethral resection of endometriotic spot is the commonly used approach but to completely excise the endometriotic nodule, bladder resection at the site of nodule is needed along with repair of cut bladder margins.
Conclusion: With advent of Robotic surgery, it has now become easier to perform such complex surgeries with better postoperative status. Preoperative DJ stenting of ureters prevents ureteric injury and with demarcation of bladder endometrioma under cystoscopy guidance, surgery becomes easier with better postoperative outcome.
★ Honorable Mention – Best Gynecology Video
Scientific Paper. SUBURETHRAL ENDOMETRIOSIS AS A CLINICAL FINDING OF EXTENSIVE DISEASE: CASE REPORT AND REVIEW OF LITERATURE
Maria A. Hincapie, Adi Katz, Ceana H. Nezhat
Objective: Endometriosis spreading to the vagina is rare, present in only 0.02% of women with symptomatic endometriosis. Suburethral lesion site is exceptional. In an extensive literature review only four cases of suburethral endometriosis were identified. We present a case of primary vaginal suburethral endometriosis in a 31 year-old patient and a literature review on this topic.
Methods and Procedures: Case report presentation based on information extracted from the patient database of Atlanta Center of Minimally Invasive Surgery and Reproductive Medicine. A review of literature with a Medline search using key words urethral endometriosis, suburethral endometriosis, urethral diverticulum, vaginal endometriosis and vulvar endometriosis was undertaken.
Results: A 31-year-old female patient referred for severe pelvic pain, worsening during menstruation. On physical examination a 2 cm suburethral lesion, enlarged and tender uterus and adnexa were found. Surgical evaluation revealed extensive endometriosis with paraaortic lymph node involvement at laparoscopic exploration. The review of literature revealed only four cases where suburethral endometriosis was previously identified.
Conclusion: Primary vaginal suburethral endometriosis, although rare, could be an indication of extensive endometriosis. This case highlights the importance of careful clinical examination for extrapelvic endometriosis in patients with pain, and laparoscopic evaluation when identifying vaginal endometriotic lesions.
Video. HYSTERO-EMBRYOSCOPY: EVALUATION AND EVACUATION OF SPONTANEOUS MISSED ABORTIONS
Maria A Hincapie, Ceana H Nezhat
Objective: To demonstrate the steps for hystero-embryoscopic evaluation of a 7-week spontaneous missed abortion and evacuation of the products of conception. Illustrate the surgical technique and highlight its advantages in improving the evaluation of spontaneous missed abortions.
Methods and Procedures: Video description of a case, demonstration of the surgical technique, and review of the advantages of this technique. Patient provided consent for the video and publication. This surgical report with no identifying patient data was exempt from Institutional Review Board approval.
Results: Following vaginoscopy, the cervix is approached without prior blind cervical dilation. Using a 2.9 mm diameter hysteroscope, navigation from the endocervix to the endometrial cavity is performed. The endometrial cavity is thoroughly inspected revealing an intact gestational sac and submucosal fibroids. The operative grasper is introduced, the chorion and amnion are penetrated and embryoscopy is performed. In flow in reduced for external morphological inspection of the embryo; it is then grasped and retrieved. The procedure is continued by introducing of a 26-french bipolar resectoscope. The product of conception are excised without electricity and sent for histologic and genetic studies. Cytogenic analysis for this case revealed a female embryo with trisomy 15. No maternal and fetal cell admixture was noted in the analysis, allowing a precise diagnosis.
Conclusion: Hystero-embryoscopy is a valuable diagnostic and therapeutic procedure for cases of missed abortion. It may reveal embryonic morphological abnormalities, expand the diagnostic spectrum in the evaluation of pregnancy loss and avoid potential complications from blind curettage.
Video. CONGENITAL SEPARATED UTERINE CERVIX AND BODY
A 12-year-old woman whose chief complaints were not having first menstruation and suffering monthly severe lower abdominal pain. Magnetic resonance imaging (MRI) showed that the uterine body was separated from the uterine cervix. Diagnostic laparoscopy confirmed that the uterine body was partially agenesis. The uterine cervix and body were connected to each other only with anterior tissues. The right tubal interstitium is not in normal position. Uterocervical anastomosis was performed under laparoscopy. Periodic menstruation started one month after operation and the abdominal pain was improved. Congenital separation of the uterine body and cervix is an extremely rare anomaly of the Müllerian ducts, this case did not correspond to the conventional classification[1]. MRI may be helpful to provide detailed anatomical location of the uterus, contributing to selection of the best treatment option.
Scientific Paper. A CASE REPORT ON PELVIC ENDOMETRIOSIS AND SUBSEQUENT DEVELOPMENT OF MULTIPLE AUTOIMMUNE MEDIATED PAIN SYNDROMES-A CONTINUUM OF DEVELOPMENT OVER 25 YEARS
Background and Objectives: Endometriosis was diagnosed in this patient at the age of 18. She subsequently had several fertility sparing laparoscopic surgeries for excision and ablation of endometriosis. Concomitant multiple large myomas were also removed over the next 15–20 years. She adopted a baby at age 44 after years of infertility and 5 attempts at IVF. At age 46 she conceived twins after IVF following laparoscopic treatment of recurrence of endometriosis and myomas. During this time she was experiencing pain syndromes-Central pain, chronic fatigue syndrome, Small fiber neuropathy, Systemic mast cell disease and Neuropathy were diagnosed. The etiology of endometriosis is largely unexplored but presence of ectopic endometrial tissues hints at it being an autoimmune mediated disease.
Method: Retrospective chart review of gynecological diagnoses and treatment over the past 25 years was conducted.
Results: The coexistence of Endometriosis and autoimmune disorders has long been studied by many scientific minds. This case report of a young lady with confirmed endometriosis and now disabled with myofascial pain syndromes shows the possible association of endometriosis and autoimmune diseases.
Conclusion: In the opinion of the author Endometriosis and coexistence of several autoimmune disorders may not be a mere coincidence. The two diseases may be independent but may share pathophysiolgical mechanisms. This area is under scrutiny and research and a well-designed large cohort studies are needed to establish a relationship between the two.
Video. KIDNEY LIVING DONOR AND RECIPIENT REHEARSAL PLATFORM UTILIZING 3D PRINTED HYDROGEL MODELS
Randeep Kashyap, Rachel Melnyk, M. Katherine Dokus, Katie Helbig, Elizabeth Belfast, Timothy Campbell, Guan Wu, Jean Joseph, Ahmed Ghazi
Introduction and Objective: Despite the successful adoption of robotic donor nephrectomy, the steep learning curve of robotic recipient transplantation has hindered the implementation of robotic assisted kidney transplantation (RAKT). We sought to develop a high-fidelity, perfused, full immersion, nonbiohazardous platform for robotic living donor nephrectomy and kidney transplantation simulation training.
Methods: A three-dimensional computer aided design (CAD) model consisting of a kidney, pelvicalyceal system, renal artery and vein was created from a CT scan of a donor nephrectomy patient. 3D printed negative casts designed from the CAD model were injected with various polyvinyl alcohol hydrogel formulations to fabricate an anatomically accurate kidney phantom and surrounding abdominal cavity. The process was repeated using a recipient’s CT scans to create the recipient pelvic model containing a bony pelvis, pelvic floor musculature, iliac arteries and veins, and bladder. Donor and recipient models each contained hollow structures to simulate the perfused vascular and ureterovesical anastomosis.
Result: The simulation models for the donor and recipient operations helped the surgeon to rehearse the operations a number of times before the actual operations as demonstrated in the video. The simulations helped to shorten the learning curve and achieve competency for vascular (arterial and venous) and bladder anastomosis times.
Conclusions: Using a combination of 3D printing and hydrogel injection casting technologies, a high fidelity, perfused, full-immersion, nonbiohazardous simulation platform for RAKT was developed to facilitate transitioning transplant surgeons towards a completely robotic approach.
★ Best Urology Video
Video. SINGLE PORT ROBOTIC ASSISTED LEFT RADICAL NEPHRECTOMY: INNOVATIVE TECHNOLOGY FOR LARGE RENAL MASSES
Salma Ahsanuddin, Mubashir S Billah, Sofia Ahsanuddin, Joshua Cadwell, Mutahar Ahmed
Objective: Single Port Robotic Assisted Laparoscopic Surgery was introduced in 2018. This new technology was a major step forward for single site minimally invasive surgery. It enables multiple instruments with fully wristed motions. Instruments are introduced through a 25 mm cannula. This video aims to demonstrate single port surgery with a truly single incision by placing the assistant port in the same incision as the robotic port. This video highlights tips and tricks for working with the single port robot.
Methods: 52-year-old male presented to the office with gross hematuria. Workup demonstrated large central left renal mass which was not amenable to partial nephrectomy.
Results: Patient underwent single port left radical nephrectomy. A single 35 mm incision was made in the umbilicus. The 25 mm robotic cannula and 10 mm assistant port were placed in the gel mini port. The approach mimicked the multiport approach. Given the large tumor size and different mobility of the single port, adjustments were made during traction and dissection.
Conclusions: The single port is a new technology that hopes to enable quicker recovery and less pain for patients. As with all new technologies, there is an associated learning curve. As opposed to previous single port technologies, the new Surgical Robot Single Port system is easy to use and accessible. It brings the complexity of single port surgery within reach of all surgeons. With time and increasing case load, single port robotic surgery can be as safe and as effective as multiport robotic surgery.
Video. ROBOTIC PYELOPLASTY IN PATIENTS WITH DUPLEX COLLECTING SYSTEM WITH LOWER POLE URETERO-PELVIC JUNCTION OBSTRUCTION AND WITH MULTIPLE CROSSING VESSELS: TIPS AND TRICKS
Cody Savage, Pankaj Dangle, Sheila Mallenahalli
Objective: To describe the technical aspects, tips and tricks with robotic assisted laparoscopic pediatric pyeloplasty in patients with complex ureteropelvic junction (UPJ) anatomy such as lower pole UPJ obstruction and those with malrotation, high insertion with multiple hilar crossing vessels.
Methods and Procedures: Key surgical steps in identification of vital anatomy, tips to preserve the vascular adventitial tissue between the duplicated ureter. Also discuss the key steps to success in unexpected anatomy of malrotation, high insertion and multiple crossing vessels and use of 4th arm for successful completion of the procedure.
Results: Here in we present successful completion of robotic assisted pyeloplasty in teenage patients with complicated ureteropelvic junction anatomy such as duplicated collecting system in a 14 yr old and a 12 year old with malrotated high insertion with multiple crossing vessels.
Both procedures were completed successfully, with complete resolution of the hydronephrosis. Use of robotic technology and assistance of 4th arm is key in malrotated high insertion UPJ obstruction and multiple crossing vessels.
Conclusion: With advances with robotic technology, it is technically feasible to complete Anderson Hynes pyeloplasty in patients with complicated UPJ anatomy such as lower pole UPJ with crossing vessel and those with malrotated, high insertion UPJ obstruction with multiple crossing vessels. Addition of 4th arm aids in better visualization, access, retraction, and successful completion.
Video. ROBOTIC APPROACH TO RETROPERITONEAL LEIOMYOSARCOMA USING A SINGLE-PORT TECHNOLOGY WITH MANAGEMENT OF DIFFICULT SITUATION
Salma Ahsanuddin, Mubashir Billah, Sofia Ahsanuddin, Joshua Cadwell, Mutahar Ahmed
Objective: Robotic-Assisted Laparoscopic Surgery is now the mainstay approach to many urologic cases, including radical adrenalectomy. Robotic-assisted surgery provides numerous benefits but can also pose unique challenges. This video aims to demonstrate managing a difficult robotic adrenalectomy case and troubleshooting failure of equipment.
Methods: The patient is a 48-year-old female presenting with abdominal pain and found to have an incidental finding of 6.5 cm right adrenal mass with MRI confirmation with very close proximity to the IVC. We evaluated the injury that happened intraoperatively, assessed how we were able to troubleshoot the issue without converting, and analyzed the factors used during dealing with this challenging case.
Results: The video outlines the process in which we were able to manage an intraoperative issue in which the vessel loop malfunctioned and failed to clamp the inferior vena cava after resection of the adrenal tumor from the IVC. The major bleeding vessel was controlled, and homeostasis regained without conversion. Full resection of the tumor continued with IVC repair taking robotically. The patient recovered well and was discharged home on postop day 4. The final pathology demonstrated leiomyosarcoma.
Conclusion: An experienced robotic surgeon with a deep understanding of the technology can manage even the most challenging intraoperative complications without the need to open. Robotic technology made it possible to control severe bleeding after the vessel loop malfunctioned and allowed IVC repair to be completed robotically.
★ Honorable Mention – Best Urology Video
Video. ROBOT-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY IN A HORSESHOE KIDNEY: USE OF INDOCYANINE GREEN AND NEAR-INFRARED IMAGING ASSISTS WITH INTRAOPERATIVE ASSESSMENT OF VASCULARITY
Bethany Desroches, Nermarie Velazquez, Ravi Munver
Objective: Nephroureterectomy in a horseshoe kidney presents challenges due to renal malrotation, anomalous vasculature, and difficulty in division of the isthmus. We present a technique for robot-assisted laparoscopic (RAL) left nephroureterectomy in a 74-year-old male with high grade upper tract urothelial carcinoma (HG UTUC) in a horseshoe kidney. Indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging was utilized to aid in division of the isthmus for maximal parenchymal preservation.
Methods & Procedures: A four-arm transperitoneal approach was used. Intraoperative ultrasound localized the renal hilum and isthmus. After transection of the renal vessels, the left renal moiety was exposed and the isthmus was identified. Intravenous injection of ICG and use of NIRF revealed fluorescence pertaining to the vascularized parenchyma of the right moiety, and absence of fluorescence in the ischemic left moiety. NIRF delineated the interface between vascularized and devascularized tissue in the isthmus. The isthmus was sharply transected with robotic scissors, and the parenchyma was oversewn using a sliding clip technique. The distal ureterectomy and bladder cuff excision were then completed.
Results: The operative time was 2 h 48 min and estimated blood loss was 70 cc. The patient was discharged on the first postoperative day and urethral catheter was removed after 6 days. Pathology revealed pTa HG UTUC of the left renal pelvis and ureter and negative surgical margins.
Conclusion: RAL nephroureterectomy in a horseshoe kidney can be facilitated with judicious use of ICG and NIRF to aid in delineation of renal vasculature, confirmation of renal moiety devascularization, and in precise transection of the isthmus.
★ Honorable Mention – Best Urology Video
Video. USE OF A BIOREGENERATIVE AMNIOTIC MEMBRANE ALLOGRAFT WRAP DURING ROBOT-ASSISTED URETEROLYSIS
Bethany Desroches, Nermarie Velazquez, Ravi Munver
Objective: Omental wrap is commonly performed following ureterolysis to prevent recurrence of periureteral fibrosis. We present a 37-year-old female with a history of two caesarean sections and laparotomy for endometriosis treatment. She subsequently developed pain due to right distal ureteral extrinsic compression requiring robot-assisted ureterolysis. We describe a novel use of a bioregenerative amniotic membrane to promote ureteral tissue healing and as an adhesion barrier to prevent recurrent fibrosis.
Methods & Procedures: Right retrograde pyelography demonstrated a long narrow area of the right distal ureter through which a flexible ureteroscope could not be advanced. A four-arm robotic approach was used. Adhesions of the intestines, appendix, and right ovary encased the right ureter, and appendectomy and right oophorectomy were performed. Robot-assisted ureterolysis was then performed. Following ureterolysis, ureteral patency was confirmed as the flexible ureteroscope successfully passed the area of the ureteral narrowing. Omental wrap could not be performed due to the absence of adequate omental tissue. As a result, bioregenerative amniotic membrane allograft ureteral wrap was performed.
Results: Operative time was 3h 28 min and EBL was 50 cc. The patient was discharged on the first postoperative day with ureteral stent removal at 4 weeks. Imaging with renal ultrasound and nuclear medicine renal scan was performed at 10 weeks and 6 months. The patient had complete symptom resolution.
Conclusion: Cryopreserved human amniotic membrane/umbilical cord tissue assists with healing while minimizing inflammation and fibrosis. Bioregenerative amniotic membrane allograft ureteral wrap after ureterolysis is a reasonable option when omental wrap is not feasible.
Video. ROBOTIC REVISION OF INDIANA POUCH WITH SUTURE PLICATION: THE FIRST REPORTED CASE
Sofia Ahsanuddin, Mubashir Billah, Salma Ahsanuddin, Joshua Cadwell, Mutahar Ahmed
Objective: Urinary diversion is a crucial component of patients undergoing radical cystectomy and pediatric patients requiring diversion. The Indiana pouch is one type of continent cutaneous diversion, but it is associated with complications reported as high as 90 percent, with reoperations often needed. Given the extensive surgery these patients undergo, reoperation can often be tricky. We aim to demonstrate a robotic approach to suture plication of the Indiana pouch continence mechanism.
Methods: The video presents a 58-year-old male with a history of muscle-invasive bladder cancer status post radical cystoprostatectomy with a continent reservoir of an Indiana pouch experiencing debilitating urinary incontinence.
Results: Upon entering the abdomen, extensive adhesions were noted, which required careful and lysis of adhesions focusing on exposing the continence mechanism without devascularization. Indocyanine green can be used in association with fluorescence imaging to confirm vascularity. Once the tissue was revealed, a suture plication was performed to narrow the lumen and improve the patient’s incontinence. A foley was placed into the stoma, and the pouch was filled to test for continence. The patient was discharged on POD1. The patient remains continent at six months follow-up.
Conclusions: Although revision of Indiana pouch is often performed open, robotic Revision of Indiana Pouch can be safely performed and provides effective outcomes. We show that revision of Indiana Pouch can be done without additional bowel harvest or conversion to incontinent urinary diversion.
Scientific Paper. THE NESA’S TRANS-DOUGLAS AND TRANS-ORAL SURGERY – STATE OF THE ART
Michael Stark, Kai Witzel, Tahar Benhidjeb
Objective: Natural Orifice Surgery (NOS) is considered as the next step in the evolution of minimally invasive surgery. Its goal is to develop procedures using natural openings and scarless operations. The first European Natural Orifice Surgery interdisciplinary working group was established by The NESA in 2006 with the aim to explore surgical accesses, develop adapted instruments, and conduct experimental and clinical studies.
Methods & Procedures: In collaboration with the Department of Anatomy at the University Hospital of Rotterdam the NESA conducted studies where the feasibility of Trans-Douglas surgeries and Transoral Thyroidectomy were confirmed. The mean fornix posterior diameter was measured 2.6 cm with a range of 2.0–3.4 cm, which enables to use up to 25 mm instruments without damage. The worldwide first transoral approach to the Thyroid could be defined and established
Results: Hundreds of Trans-Douglas surgeries were already performed, although mainly as hybrid operations due to lack of designed instruments. The Transoral Thyroidectomy is already in use in several countries using endoscopic instruments and/or robotics.
Conclusion: NOS represents a paradigm shift in surgery. Despite all the achieved benefits along with an equal safety profile compared with laparoscopy in Thousands of patients, a fading interest of the surgical community in NOS is evident, maybe due to the lack of designed instruments. Other reasons why NOS has not been widely adopted in current medical practice by surgeons, as happened with laparoscopic techniques, is a question that might be answered by performing surveys involving physicians in general and surgeons in particular.
Poster. EARLY STAMM GASTROSTOMY DISLODGEMENT RESCUED BY VIDEO LARYNGOSCOPE
Marycarmen Mendoza, Marina Trimmer, Adolfo Leyva, Hector Alejandro Rodriguez
Complications associated with gastrostomy tube placement may occur at any time following the tube placement, these include infection, bleeding, peristomal leakage and tube removal or dislodgement. Gastrostomy tubes may be inadvertently detached if traction is placed on the tube, which makes it a relatively common complication. Early management with immediate imaging, antibiotics and surgical evaluation should be prioritized in order to prevent further complications. The development of the case at hand, started with a 65 year old man with a familiar history of Peptic ulcer disease, that had an interconsultation placed by the internal medicine service for the surgical management of secondary dysphagia due to a mediastinal mass that caused a mass effect and constriction of the lower third of the esophagus. Due to the constriction of the lower esophagus, a surgical Stamm gastrostomy was installed. Around 24 hrs after its placement, the gastrostomy tube was inadvertently dislodged. Our focus is based on the early rescue, without operation, of the gastrostomy tube by minimal invasion technique with the successful use of video laryngoscope. After 4 days of the rescue, the rescued gastrostomy tube remains in its optimal, functional and anatomical condition.
★ Gustavo Stringel Award for Best Poster
Poster. ROBOTIC-ASSISTED PRE-PERITONEAL APPROACH FOR GIANT RETZIUS SPACE LIPOMA
Ana I. Vargas, Minerva Romero-Arenas
Objective: We report a rare case of a giant Retzius space lipoma that was treated successfully with Minimally Invasive Surgery (MIS) through Robotic assisted preperitoneal approach.
Methods & Procedures: A 37-year-old Hispanic male presented to the clinic due to an incidental pelvic mass found on computed tomography (CT) imaging, obtained as part of an evaluation for persistent a symptomatic microhematuria. A 12.5 cm lipomatous pelvic mass displacing the bladder posteriorly and to the left was seen (Figure 1). He was offered MIS with Robotic assisted preperitoneal approach for excision of the pelvic mass.
Results: Three robotic ports were used. We found that the medial umbilical ligament was displaced by the mass to the left. The balloon of the Foley catheter was identified to avoid inadvertent injury to the bladder. The right preperitoneal space was accessed and the mass was dissected easily from adjacent structures, rest of the space anatomy was identified and preserved, the preperitoneal flap was suture closed and mass extracted successfully through an extended incision in the umbilical port. Pathology report was consistent with benign giant lipoma, MDM2 and CDK4 negative.
Conclusion: Several techniques have been described to access the space of Retzius, laparoscopic approach has been preferred since the 1990s to provide better visualization of this space. The use of robotic surgery has also allowed improved dexterity in dissection during prostatectomies and inguinal hernia repairs, which may facilitate dissection of these lipomas without disruption. To our knowledge this is the first robotic excision of Retzius space lipoma reported.
Poster. ARTIFICIAL INTELLIGENCE SOFTWARE: CAN IT HELP SURGEONS PERFORM LAPAROSCOPIC CHOLECYSTECTOMY?
Jacqueline M. Hausner, Sahar Sorek, Matthew A. Brett, Justin Walters, Stephen DiRusso
Background and Objectives: Bile Duct Injury (BDI) is a devastating adverse outcome of Laparoscopic Cholecystectomy with an incidence of 2,500/year.1,5 A major reported risk factor for BDI is the misidentification of important anatomical landmarks.2,4 One potential strategy to decrease the incidence of BDI is with identification of the Critical View of Safety (CVS) using the software Cholecystectomy AI/Surgeon’s JARVIS.3. As far as we are aware, no clinical studies have been done to see whether this is a viable tool for surgery.
Study Design and Methods: We selected and analyzed eight photos using the A.I.—four that achieved the CVS, and four that didn’t. We chose the photos based on a 6-point criteria for judging the CVS.6. The A.I. evaluates clearing the hepatocystic triangle, exposing of the cystic artery and duct, and lifting the gallbladder off the cystic plate. Other values shown represent how much is left in the task.
Results: Fig. 1-Fig. 4 are analyses performed by Cholecystectomy AI/Surgeon’s JARVIS with Critical Views, the probabilities in these range 89.06–95.31%. Fig. 5-Fig. 8 are analyses with poor Critical Views; the Critical Views for these range 5.47–44.53%. To evaluate the linear relationships between the A.I. Critical View and the 6-Point Scale, we used Pearson’s Correlation. Accordingly, the linear relationship was 0.84 (p = 0.009).
Conclusion: These analyses confirm the ability of Cholecystectomy AI/Surgeon’s JARVIS to discriminate between a well-achieved Critical View of Safety and a poorly achieved one. Furthermore, statistical analysis suggests that the A.I. correlated well with analysis of experienced surgeons using 6-point criteria.
★ Gustavo Stringel Award for Best Poster by a Student
Poster. STANDARDIZATION OF LAPAROSCOPIC TRAYS USING AN INVENTORY OPTIMIZATION MODEL TO PRODUCE IMMEDIATE COST SAVINGS AND EFFICIENCY GAINS
Jin Tong Du, Ajay Shah, Aazad Abbas, Jay Toor
Introduction: The configuration of surgical trays can be an ongoing source of excess cost. Standardization of surgical trays can be achieved in two ways: 1) procedure-specific trays or 2) a single standardized tray that can be used in numerous procedure types. In this observational study, we aim to determine the cost savings from the standardization of laparoscopic surgery instrument trays.
Methods: Utilization of instruments on the General Surgery (GS), Gynecology (GY), and Gynecological Oncology (GO) trays were documented. Observational results were applied to a customized single-period inventory mathematical model to determine the configuration for a standardized laparoscopic (SL) tray and Minimal Stock Quantity (MSQ). Preand postintervention costs were assessed. The SL tray was trialled in the OR.
Results: Prior to standardization there were three procedure-specific tray types: GS, GY and GO with a total inventory size of 309 instruments, and a MSQ of 23 trays. This corresponded to a procurement cost of $304,906 and reprocessing cost of $41,725. Standardization yielded a MSQ of 17 SL trays. The total inventory decreased to 255 instruments, corresponding to a procurement cost of $261,429 and reprocessing cost of $41,572. After 33 trial surgeries, there were no requests for additional instruments and user satisfaction improved from 50% to 97% (P < .001).’
Conclusion: Standardization to a single tray led to significant savings of 14.2% by reducing the MSQ from 23 to 17. Surgeons and managers looking to increase efficiency and reduce costs should consider this comprehensive but simple approach.
Poster. VALIDATION OF A LAPAROSCOPIC URETEROLYSIS SIMULATION MODEL FOR GYNECOLOGY AND UROLOGY RESIDENT TRAINING
Ashlee N. Green, Aileen Baffo, Eugenia Girda, Ruth Stephenson, Aliza Leiser, Sammy E. Elsamra, Alexandre Buckley de Meritens
Objective: Incidence of ureteral injury during benign hysterectomies is 3.1% and a concern in other laparoscopic procedures. Residents should be trained to safely identify and dissect the ureter. We developed a ureterolysis simulation model to improve resident training. We hypothesize that this model will simulate intraoperative ureterolysis, discriminate between experts’ and trainees’ performance, and serve as an effective training tool.
Methods: We developed a model of the female pelvis. All participants were shown a video demonstrating how to identify the ureter. Participants were videotaped performing the task at their first, tenth, and twentieth attempt. Performance was scored by two blinded expert laparoscopic surgeons using the Global Operative Assessment of Laparoscopic Skills (GOALS) score. Performance was measured over time. Scores were compared using a Wilcoxon signed rank test. Sample size was calculated predicting a 15 points difference in GOALS score at the first attempt comparing experts and trainees.
Results: The mean GOALS score at first attempt was 29.8 for trainees and 41.6 for experts. The mean difference was 11.8. Trainees made significant improvement between the 1st and 10th attempt but no significant improvement between attempt 10th and 20th. All experts scored the model with high fidelity and validity scores.
Conclusion: The study did not show the expected difference of 15 in overall GOAL score between experts and trainees. However, the model successfully improved trainees performance by attempt ten.
★ Gustavo Stringel Award for Best Poster by a Resident
Poster. ROBOTIC APPROACH TO URINARY TRACT ENDOMETRIOSIS: LITERATURE REVIEW
Jordanna Santanna Diniz Moura, Pedro, Henrique Jaime E. Silva, Daniela Jaime E. Silva
Objective: To review the use of robot-assisted laparoscopy in the treatment of urinary tract endometriosis.
Methods & Procedures: Published studies on the treatment of urinary tract endometriosis through robotics were analyzed. A bibliographic survey was made as a research source using the terms “endometriosis”, “urinary tract”, “robotics”.
Results: The incidence of urinary tract endometriosis is 1–3%, in which about 90% of cases involve the bladder and ureters. Symptoms are dysuria, suprapubic pain and tenesmus, but vary depending on the size and location of the lesion. The laparoscopic approach has benefits in the treatment of deep endometriosis and robot-assisted laparoscopy can be useful in the treatment of extensive injuries, with less morbidity as it provides a three-dimensional view, excellent visualization of the surgical field, better range of motion and ergonomics for the surgeon. Endometriosis of the urinary tract can affect the bladder, ureter and kidneys, with the bladder being the most affected site, followed by the ureter and kidneys, in a proportion estimated at 40: 5: 1. Surgical treatment, on the other hand, has a significantly higher success rate, improving symptoms and preventing, although rare, the malignant transformation of bladder endometriosis lesions. The robot-assisted technique supports the surgeon by having greater precision of movements, achieving better surgical amplitude and performing more intuitive movements.
Conclusion: The literature presents cases of treatment of robot-assisted urinary tract endometriosis, bringing favorable results. However, more studies are needed to fully assess the benefits offered to patients, in view of the high cost of the device used.
Poster. VIDEOLAPAROSCOPIC APPROACH ASSISTED BY ROBOTICS IN ENDOMETRIOSIS: SISTEMATIC REVIEW
Jordanna Santanna Diniz Moura, Pedro Henrique Jaime E Silva, Daniela Jaime E Silva
Objective: Understand the advantages and disadvantages of robotic surgery in endometriosis compared to conventional laparoscopy.
Methods & Procedures: Systematic review with articles selected from Scielo and Pubmed databases.
Results: The excellent surgical treatment in Endometriosis is done by minimally invasive methods. Therefore, robotic surgery is an innovative procedure that promises a better approach. Recently, laparoscopy can be performed using two methods: conventional and robotic. Camran et al. reports as a disadvantage the average surgical time, being greater in robotic surgery (135 vs 196 minutes). The instrumentalization of the robot contributes to this increase. In addition, it reports that 76.9% (210/273) of patients undergoing conventional laparoscopy were discharged on the same day of the operation, unlike in robotic surgery in which 100% (147/147) were discharged the day after of the procedure. Nezhat et al. states that robotic laparoscopy is associated with higher costs due to longer surgery and hospital stay in the postoperative period. In contrast, Mohamed et al. concludes that the technique is better than conventional videolaparoscopy in the treatment of grade III and IV endometriosis, following advantages: depth perception with three-dimensional vision, ease in the resection of infiltrative lesions, in addition to improving the surgeon’s accuracy. Nezhat et al. suggest that the robotic platform, due to its cost and complexity, should be used only for complex procedures.
Conclusion: Studies demonstrate that the two techniques do not have great differences in their results, while others point out that the use of robotic surgery can overcome some limitations of conventional laparoscopy. More studies must be done.
Author Index
A
Abbas, Aazad, 21
Aguayo, Pablo, 6
Ahmed, Ali, 1
Ahmed, Mutahar, 11, 18, 19
Ahsanuddin, Salma, 11, 18, 19
Ahsanuddin, Sofia, 11, 18, 19
Ajao, Mobolaji, 5
Amodu, Leo, 3
Arcerito, Massimo, 15
Ariza, Anibal, 4
Attiyeh, Marc A., 1
B
Baffo, Aileen, 21
Bahadur, Anupama, 5, 16
Barton, Jeffrey S, 4
Belfast, Elizabeth, 18
Benhidjeb, Tahar, 20
Benlolo, Samantha, 7, 8, 11
Betova, Tatyana, 3
Bhattacharyya, Eesha, 10
Billah, Mubashir S., 11, 18, 19
Bonomo, Giovanni, 4
Bourgoin, Michael, 3
Brand, Timothy C., 12
Brathwaite, Collin, 3
Brentnall, Mark, 10
Brett, Matthew A., 20
Briggs, Kayla B, 6
Brown, Zachary, 1, 2
Bucknor, Adjoa A, 10
C
Cadwell, Joshua, 11, 18, 19
Calming, Maria Minerva P, 3
Campbell, Timothy, 18
Canton, Silvio Alen, 15
Champion, Nicholas, 15
Chaurasia, Sunil Kumar, 16
Cho, Maureen, 6
Choong, Kevin C., 1
Clapp, Benjamin, 13
Crespo, Kaitlyn, 1
D
Dangle, Pankaj, 18
Davis, Kurt G, 4
Dekonenko, Charlene, 6
Desroches, Bethany, 12, 19
Diaz, Carlos, 4
Dimitrov, Dimitar Georgiev, 14
Dimitrov, Dobromir D., 3
Diniz Moura, Jordanna Santanna, 21
DiRusso, Stephen, 20
Dokus, M. Katherine, 18
Du, Jin Tong, 21
E
Einarsson, Jon I, 5
Elfeky, Amro, 9
Elsamra, Sammy E., 21
Epp, Annette, 8
F
Feuer, Gerald A., 4, 14
Fraser, James A., 6
Fraser, Jason D., 6
G
Gaddis, Bradley, 2
Gaitán, Laura, 4
Garcia, Omar F Duenas, 16
Ghazi, Ahmed, 18
Gibbs, Karen E., 4, 15, 16
Girda, Eugenia, 21
Goodwin, Alexandra I., 8
Gorchev, Grigor Angelov, 14
Green, Ashlee N., 21
Gupta, Shabnam, 5
H
Hajirawala, Luv, 4
Hakmi, Hazim, 3
Hausner, Jacqueline M., 20
Helbig, Katie, 18
Hendrickson, Richard J, 6
Herzog, David, 9
Hincapie, Maria A., 16, 17
I
Iliev, Sergey, 3
Isaias Dela Paz, Michael Dennis, 3
Islam, Shahidul, 3
Ivanov, Tsvetomir M., 3
J
Jacoby, Harel, 1
Jain, Dr. Nutan, 6
Joseph, Jean, 18
Jr, John P. Lenihan, 10
Juang, David, 6
K
Kannan, Umashankkar, 1, 2
Kapoor, Dhriti, 16
Karamanliev, Martin P., 3
Kashyap, Randeep, 18
Katz, Adi, 16
Kaur, Harpreet, 15
Khalil, Susan, 10
King, Louise P., 5, 13
King, Natalie, 1, 2
Kives, Sari, 7, 11
Kleinberg, Katherine A, 13
Klinger, Aaron, 4
Krishnan, Varun, 4
Kumari, Payal, 5
L
Lakhi, Nisha, 14
Leiser, Aliza, 21
Leonardi, Claudia, 4
Lewis, Aaron, 1
Leyva, Adolfo, 20
Lyubenov, Aleksandar Dimitrov, 14
M
Maghsoudlou, Parmida, 5
Mallenahalli, Sheila, 18
Manayan, Olivia, 10
Marquez, Alfonso, 4
Marroquin, Lina, 4
McCaffrey, Carmen, 7
Medge, Octavia, 14
Meffe, Filomena, 11
Melnyk, Rachel, 18
Mendoza, Marycarmen, 20
Mendoza, Miguel C., 3
Meritens, Alexandre Buckley de, 21
Miazga, Elizabeth, 7, 8
Moon, John T, 15
Moura, Jordanna Santanna Diniz, 22
Mousavi, Idine, 14
Mukherjee, Indraneil, 4, 15, 16
Mundhra, Rajlaxmi, 5, 16
Munver, Ravi, 12, 19
Munver, Sujan, 12
N
Namazi, Golnaz, 13
Narain, Sachin, 13
Narain, Shreya, 13
Narula, Nisha, 4, 16
Nensi, Alysha, 7, 8, 11
Nezhat, Ceana H., 4, 6, 16, 17
Nezhat, Farr, 9
Nicholson, Kaitlin, 8
O
Odunsi, Tosin, 4
Oliver, Diego Monasterio, 15
Orady, Mona E, 11
Orangio, Elyse RBevier-RawlsGuy R, 4
Oulton, Zachary, 1, 2
Over, Alexandra I, 15
Oyetunji, Tolulope A, 5, 6
P
Paek, Se Hyun, 11
Pan, Hongxin, 17
Pasquali, Claudio, 15
Paz, Michael Dennis Isaias Dela, 13
Petrone, Patrizio, 3
Plewniak, Kari, 7
Prandzhev, Georgi Danielov, 14
Przetocki, Valerie, 1
Q
Qin, Lei A, 10
Quach, Helen, 2
R
Rao, Shalinee, 16
Raymundo, Thiers Soares, 7
Rentea, Rebecca M, 6
Rey, David Durán, 12
Robertson, Deborah, 7, 11
Robles, Yarret, 2
Rodriguez, Hector Alejandro, 20
Romero-Arenas, Minerva, 20
Rosemurgy, Alexander, 1, 2
Ross, Sharona, 1, 2
S
Sánchez-González, Patricia, 14
Sanchez-Margallo, Francisco M., 12, 14
Sánchez-Margallo, Juan A., 12, 14
Saldivar, J. Salvador, 13
Salom, Emery M., 8
Sardzinski, Emily, 1, 2
Sarrel, Sallie, 7
Savage, Cody, 18
Schwartz, Benjamin M., 8
Seraji, Shadi, 9
Shah, Ajay, 21
Shapera, Emanuel A., 1, 2
Shapiro, Robert E, 16
Sherwani, Poonam, 16
Shiki, Yasuhiko, 8, 9
Shimotake, Lisa Y., 4, 15, 16
Shin, Ja Hyun, 7
Shore, Eliane, 7
Silva, Daniela Jaime E., 21, 22
Silva, Pedro Henrique Jaime E., 21, 22
Simmonds, Christopher, 10
Simpson, Andrea, 7, 11
Singh, Gagandeep, 1
Snyder, Charles L, 6
Sonoda, Toyooki, 3
Sorek, Sahar, 20
Soroka, Dana, 8
Sowby, Taralyn C., 8
St Peter, Shawn D, 6
Stark, Michael, 20
Stemple, Megan, 16
Stephenson, Ruth, 21
Sucandy, Iswanto, 1, 2
Sun, Zhiwei, 2
Sunyec, Alec, 16
Svetanoff, Wendy Jo, 5, 6
Swor, Gregory M., 10
Syblis, Cameron, 1
Syed, Radha, 9, 17
T
Tiu, Alexandru Negoita, 14
Tiu, Calin I, 14
Tiu, Vlad Eugen, 14
Tomov, Slavcho Tomov, 14
Toomey, Paul, 1, 2
Toor, Jay, 21
Torregrosa, Lilian, 4
Trimmer, Marina, 20
Tsai, Thomas C, 13
V
Vargas, Ana I., 20
Vasanthakumar, Prakash, 1
Velazquez, Nermarie, 12, 19
W
Walburger, Rayna M., 16
Walters, Justin, 20
Wang, Junnan, 2
Weaver, Katrina L, 5
Winnick, Aaron, 9
Witzel, Kai, 20
Wu, Guan, 18
Y
Yi, Johnny, 12