30th International Congress of the European Association for Endoscopic Surgery (EAES) Kraków, Poland, 5–8 July 2022

Karl Storz—EAES award session

HEPATO-BILIAIRY and PANCREAS—Gallbladder

O115—Emergency Biliary Care and Laparoscopic Cholecystectomy provision: Service Quality Improvement

Clare Hammer ¹, J. O'Brien¹, T. Pencavel¹

¹Royal Surrey Hospital, Hepatobiliary Surgery, United Kingdom

Aims: Early laparoscopic cholecystectomy < 8 days from acute biliary presentation results in improved outcomes. Guidelines suggest > 80% of eligible patients should undergo this. Following CholeQuic-ER, evaluating biliary care nationally, hospital episode statistics (coding) for this trust showed only 20% compliance. A laparoscopic cholecystectomy quality improvement project was therefore initiated.

Methods: Prior to CholeQuic-ER, we evaluated current practice—biliary referrals, laparoscopic cholecystectomy < 8 days from diagnosis, elective waiting lists and provision of weekend abdominal ultrasound service (USS). Through retrospective analysis of the medical notes, hospital episode statistics (coding) was analysed for accuracy and compared to actual clinical practice.

Interventions included stakeholder consultation (A&E/ radiology/ cholecystectomy surgeons/ theatre staff). A pathway encompassing current guidelines was disseminated via education, trust induction and a protocol including increased USS provision (4 weekday and 2 weekend patients per day), theatre (1 session per week) and senior clinician led coding of discharge and theatre paperwork. The service was then re-evaluated.

Results: Audit of the hospital episode statistics showed 60% of patients were incorrectly coded. Of those correctly coded, 58% of eligible patients received laparoscopic cholecystectomy < 8 days from diagnosis. 21% of patients on the elective waiting list for laparoscopic cholecystectomy had previous attendance(s) for biliary pathology and 39% were not referred for surgery following those attendances. 70% of weekend biliary USS requests were not performed. Areas for improvement were therefore targeted as referral for surgery, prompt USS (including out of hours), increased theatre capacity and more accurate coding for hospital episode statistics. Post intervention, 100% of eligible patients underwent cholecystectomy within 8 days (joint-best UK outcome). No patients on the elective waiting list had an emergency admission. Our 'Best in Study' award from CholeQuic-ER was confirmed with the hospital episode statistics, which have improved accuracy following senior input into coding.

Conclusion(s): Results confirm significant quality improvement for patients presenting with acute biliary pathology. From an initial 20% compliance rate according to hospital episode statistics (58% when corrected for coding error), we achieved 100% of eligible patients receiving cholecystectomy < 8 days. These interventions could be disseminated to gain better outcomes nationally.

COLORECTAL—IBD

O116—Characteristics of the Appendix on Intestinal Ultrasound: a Prospective Cross-Sectional Study in Ulcerative Colitis Patients and Healthy Controls

Maud Reijntjes ¹, F. de Voogd², W. Bemelman¹, G. d'Haens¹, C. Buskens¹, K.B. Gecse¹

¹Amsterdam UMC, locatie AMC, Surgery, The Netherlands, ²Amsterdam UMC, location AMC, Gastro-enterology, The Netherlands

Background: Increasing evidence suggests a role for the vermiform appendix in onset and relapse of ulcerative colitis (UC). Consequently, appendectomy is increasingly being seen as a potential alternative treatment. As a recent study suggests that patients with histological appendiceal inflammation are most likely to respond, pre-operative identification of ulcerative appendicitis could be beneficial. Intestinal ultrasound (IUS) is increasingly utilized in the diagnosis and follow-up of patients with UC. The objective of this study was to characterize the appendix by IUS in UC patients with active and quiescent disease and healthy controls.

Methods: In this cross-sectional prospective observational cohort study, we performed appendiceal IUS on UC patients with active (A) disease (FCP > 250 and SCCAI > 5) and quiescent (Q) disease (FCP < 150 and SCCAI ≤ 5) followed by age- body mass index index- and gender- matched healthy (H) controls. During IUS, the appendix was identified by a bowel structure with cecal origin and a blind ending tip. IUS still images and cineloops were centrally and blindly read by an IUS expert (> 1000 examinations). Primary outcomes were signs of appendicitis on IUS, defined as a > 6 transverse appendiceal diameter (average of a cross-sectional and longidutinal measurement), hyperaemia (using the modified Limberg score), presence of peri-appendiceal fat and fluid and compressibility.

Results: Out of 95 (A n = 35, Q n = 30, H n = 30) included patients, the majority (n = 58, 61.1%) had a visible appendix on IUS, which was similar among cohorts (p = 0.56). The appendiceal diameter measured > 6.0 mm in a significantly higher proportion of active UC patients (A: 45.5%, Q: 5.6%, H: 0.0%, p = 0.01). An increased diameter occurred irrespective of disease extent (42.9% of E1/E2 endoscopic active patients). Although the appendiceal diameter was higher for UC patients (Q–H p = 0.02, A-H p < 0.01), no significant difference between A and Q patients was found (p = 0.15, Fig. 1). A higher proportion of UC patients had incompressibility when compared to healthy controls (Fig. 2, p = 0.02). Hypervascularity was present in 54.5% of active UC (Fig. 2, p  = 0.02).

Conclusion: Appendiceal IUS was feasible in UC patients. Characteristics of appendiceal inflammation of IUS were reported for UC patients, as both the transverse appendiceal diameter and incompressibility rates were significantly higher in UC patients when compared to healthy controls. Correlating appendiceal IUS findings to histological inflammation could contribute to identifying UC patients most likely to benefit from appendectomy.

COLORECTAL—Benign

O117—Impact of Preoperative Bowel Preparation with Peroral Antibiotics on Complications in Elective Laparoscopic and Open Right Colon Surgery

Dana Sochorova ¹, T. Grolich², L. Kunovsky³, Z. Kala²

¹University Hospital Brno, Faculty of Medicine, Masaryk University, Surgery, Czech Republic, ²University Hospital Brno, Faculty of Medicine, Masaryk University, Department of Surgery, Czech Republic, ³University Hospital Brno, Faculty of Medicine, Masaryk University, Department of Gastroenterology and Internal Medicine, Czech Republic

Aims: The role of preoperative mechanical bowel preparation (MBP) has been discussed since 1970s, alongside Enhanced Recovery After Surgery (ERAS) pathways. The impact on postoperative complications, particularly when combined with preoperative peroral antibiotics (ATB), remains a clinically important topic, affecting both morbidity and mortality. Our aim was to evaluate postoperative complications rate in elective right colon surgery at our institution who were given preoperatively peroral antibiotics as part of bowel preparation.

Methods: We retrospectively analyzed elective operations performed at University Hospital Brno (January 2019-December 2020), including both laparoscopically-assisted and open right hemicolectomies, ileo-caecal resections and stoma reversals with ileo-colonic anastomosis formation. Data on demographics (Table 1), indications for surgery and the rate of surgical complications were collected (SSI, anastomotic leak, ileus, clostridium difficile infection)

Results: After excluding acute patients, we selected 70 patients who received mechanical bowel preparation, either polyethylene glycol (PEG) or magnesium sulphate (Mg) a day prior to surgery. All patients received standard surgical prophylaxis in the form of intravenous antibiotics as per local policy. Patients in the ATB group received neomycin + metronidazole a day prior to operation. Out of total 70 patients, 21 (30%) patients had at least 1 surgical complication. In the ATB group, complications occurred in 7 (20%) cases, 2 patients were re-operated. In the non-ATB group, complications were detected in 14 (40%), 7 patients returned to theatre (p-value 0,11 and 0,15). The rate of complications is summarized in Table 2.

Conclusion: While there was no statistical difference in the complication rate between ATB and no ATB group, we proved a clear trend that complications are more frequent if peroral antibiotics were not administered, especially in the case of SSI. What´s more, Clostridium difficile infection as the common argument against ATB use was not supported by our findings. The overall complication rate was lower in the ATB group, proving that their use is safe. To achieve statistical difference, the above findings should be confirmed on a larger cohort.

UPPER GI—Esophageal cancer

O118—Minimally Invasive Cervical Esophagectomy (MICE): First results of the Pilot Study

Linde van Veenendaal ¹ , R. Vercoulen¹, A. Shiozaki², H. Fujiwara², C. Rosman¹, B.R. Klarenbeek¹

¹Radboudumc, Department of Surgery, The Netherlands, ²Kyoto Prefectural University of Medicine Hospital, Department of Surgery, Japan

Aim: Radical surgical resection remains the cornerstone of curative treatment for patients with esophageal cancer. Transthoracic minimally invasive esophagectomies have reduced the occurrence of pulmonary complications, however the procedure is still associated with significant morbidity. The Minimally Invasive Cervical Esophagectomy (MICE) is a recently developed surgical technique in Japan. The procedure combines a laparoscopic transhiatal and single-port transcervical mediastinal dissection and aims to ensure a radical oncological resection with a reduction of pulmonary complications because a thoracotomy/scopy is avoided. Potential drawbacks may be an increased incidence of recurrent laryngeal nerve paresis (RLNP) and learning associated morbidity. To date, this technique is not routinely performed in European esophageal cancer patients. We aim to assess the safety and efficacy of the MICE procedure in Dutch patients with esophageal carcinoma.

Method: A prospective pilot study was performed including consecutive patients undergoing MICE for esophageal cancer.

Results: A total of twenty patients were included. The male/female ratio was 16:4 with a median age of 71 years and a ASA physical status classification grade of I, II and III in one, 11 and eight patients, respectively. Median operation time and blood loss was 350 min (IQR 326-360 min) and 100 ml (IQR 50-175 ml). Conversion occurred in five patients (20%). Recurrent laryngeal nerve paralysis was seen in seven patients (35%), at least six of which were temporary (30%). Anastomotic leakage occurred in three patients (15%), grade 1/3 according to the Dutch Upper GI Cancer Audit. Pneumonia, chyle leakage and hemothorax all occurred once in different patients (Clavien-Dindo grade 2, 4 and 3a, respectively). The median length-of-stay was nine days (IQR 7-10 days).

Conclusion: MICE is a novel minimally invasive surgical technique which seems safe and effective to perform in Dutch patients with esophageal carcinoma. As expected, a higher incidence of RLNP was seen, but often only temporarily. Long-term safety and effectiveness will be prospectively evaluated in a larger population.

HERNIA-ADHESIONS—Emergency surgery

O119—Prognostic Factors in Patients with Acute Mesenteric Ischemia: A Novel Tool for Determining Patient Outcomes

Marcel Schneider1, S. Sinz¹, S. Graber², H. Alkadhi², A. Rickenbacher¹, M. Turina¹

¹University Hospital of Zurich, Department of Surgery, Switzerland, ²University Hospital of Zurich, Department of Radiology, Switzerland

Aims: Acute mesenteric ischemia (MI) is a devastating disease with poor prognosis. Due to the multitude of underlying factors and broad clinical presentation, prediction of outcomes remains poor. Here, we aimed to identify factors governing survival in MI and develop a novel prognostic tool.

Methods: The present study is a monocentric retrospective analysis of patients with suspected MI undergoing imaging between January 2014 and December 2019. Primary endpoint was identification of factors influencing survival in patients undergoing surgery for confirmed MI, secondary endpoint was the development of a predictive nomogram to aid in determination of patient prognosis.

Results: 539 patients underwent CT imaging for suspected MI, 216 of which had radiological indication of MI and 137 of those had subsequently confirmed MI. Factors associated with confirmed ischemia were increasing age, nausea/vomiting, history of peripheral arterial disease and presence of pneumatosis intestinalis and dilated bowel loops. 125 patients underwent surgery, 58 of which survived, and 67 died (median 9 days after diagnosis, IQR: 22). Baseline characteristics, including time from diagnosis to surgery were not different among patients, and outcomes were not affected by the presence of a surgical senior consultant or daytime of the operation. A minimally invasive approach was attempted more often in survivors (25.9% vs. 10.4%, p = 0.024), however, in all but 1 patient (1.7%) conversion to open surgery was performed following detection of ischemia. Increasing age and ASA score, type 2 diabetes, decreased haemoglobin and pH, increased creatinine, radiological atherosclerosis, vascular occlusion (versus non-occlusive MI) and affection of the colon (compared to small bowel ischemia only) were independently associated with impaired survival. Based on a multivariate model, we developed a nomogram for survival prediction, which showed adequate power upon internal validation (C-index = 0.738, Fig. 1).

Conclusion: Acute MI remains a condition with high mortality. Here, we identified factors affecting survival after MI, namely colonic involvement, vascular co-morbidities and increasing age. Minimally invasive surgical approaches have not yet gained widespread acceptance in treatment of confirmed MI. Our novel nomogram might prove helpful in outcome prediction of patients with MI.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O120—Outcomes of the Post-cholecystostomy Cholecystectomy

James Lucocq ¹, P. Patil¹, J. Scollay¹

¹Ninewells Hospital, Department of General and Upper GI Surgery, United Kingdom

Introduction: Cholecystectomy may be offered to patients with a previous cholecystostomy. Understanding the rates of peri-operative morbidity in these patients is vital to inform both surgical decision-making and the consent process. The present large cohort study compares the morbidity of the post-cholecystostomy cholecystectomy (PC) with conventional cholecystectomy (CC).

Methods: All laparoscopic cholecystectomies between 2015 and 2020 in one health board were included. Pre-operative characteristics and peri-operative outcomes were compared between PC (n = 40) and CC (n = 2728) groups using univariate analysis. Patients were followed up for 100-days post-operatively for adverse outcomes.

Results: Patients in the PC group were older, more likely to be male, had more comorbidities, higher pre-operative inflammatory markers, more previous admissions and were more likely to have cholecystitis (p < 0.05). The PC group had higher rates of subtotal cholecystectomy (20% vs. 3.2%; p < 0.001), conversion to open (5.0% vs. 1.1%; p = 0.019), intra-operative drains (42.5% vs. 7.0%; p < 0.001), post-operative imaging (20% vs. 9.7%; p = 0.030), post-operative intervention (10% vs. 3.3%; p = 0.020) and prolonged post-operative stay (45% vs. 10.2%; p < 0.001). The median operative time was higher in the PC group (120 min vs. 74 min; p < 0.001). There were no statistical differences in intra-/post-operative complication or readmission.

Discussion: The post-cholecystostomy cholecystectomy is considerably more challenging than conventional cholecystectomy and this should be acknowledged in the surgical decision making process and during patient consent.

HERNIA-ADHESIONS—Adhesions

O121—Prospective Nationwide Audit of the Management of Adhesive Small Bowel Obstruction in the Netherlands: A Snapshot Study

Richard ten Broek ¹, L. Kranebrug¹, P. Krielen¹, H. van Goor¹, N. Bouvy²

¹Radboud University Medical Center, Surgery, The Netherlands, ²Maastricht University Medical Center, Surgery, The Netherlands

Introduction: Adhesive small bowel obstruction (ASBO) is a frequent abdominal surgical emergency, and is a leading cause of morbidity and mortality in emergency surgery [1, 2]. Adhesions develop in 70-90% of patients undergoing abdominal surgery, exposing them to a 9-15% lifelong risk of ASBO. Remarkably, literature on the optimal management of ASBO is limited, and there is wide practice variation [3].

Methods: A nationwide prospective observational cohort study was performed using a snapshot design. All patients with clinical signs of ASBO admitted to the hospital were included during six months with a three month follow-up. Digital questionnaires on diagnosis, treatment and outcome, were completed by local research partners.

Results: 510 patients with a clinical suspicion of ASBO were included, 382 (74.9%) had a final diagnosis of ASBO. A CT scan was performed in 330 cases (86.4%) of which 300 (90.9%) within 24 h from admission. 71 (18.6%) of patients with ASBO were treated by emergency surgical exploration, 311 (81.4%) were initially treated by non-operative management (NOM). 119 (31.1%) were operated after failure of NOM, so eventually 192 (50.3%) patients were treated by NOM and 190 (49.7%) surgically. Overall mortality from ASBO was 3.1%, with a median length of stay of 5 days and 90- day readmission rate of 14.7%. For the non-operative group mortality was 1.6% with a median length of stay of 3 days. Of surgical interventions, 51.1% was started by laparoscopy of which 36% converted to laparotomy. Within the cross over group mortality was 4.2% and length of stay 11 days. The initial operative group had a mortality of 5.6% and median length of stay of 7 days.

Conclusion: Preliminary results of our snapshot study show an ongoing high burden of ASBO. Laparoscopy for ASBO was performed in almost half of all patients who underwent emergency surgery, however with a one in three conversion rate. Further analysis of our data will demonstrate the impact of practice variation and laparoscopy on clinically relevant parameters.

References

• 1. ten Broek, R.P., et al., Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ, 2013. 347: p. f5588.

• 2. NELA Project Team. Sixth Patient Report of the National Emergency Laparotomy Audit RCoA London 2020

• 3. ten Broek, R.P.G., et al., Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg, 2018. 13: p. 24.

GERHARD BUESS EAES TECHNOLOGY AWARD SESSION

ROBOTICS & NEW TECHNIQUES—Education

O134—Environmental Sustainability in Minimally Invasive Surgery: A Systematic Review

Audrey Jongen ¹, A. Papadopoulou², N. Niraj², A. Vanhoestenberghe³, N. Francis⁴

¹Catharina Hospital Eindhoven, Department of Surgery, The Netherlands, ²University College London, Division of Medicine, United Kingdom, ³UCL Institute of Orthopaedics and Musculoskeletal Sciences Royal National Orthopaedic Hospital (RNOH), Department of Orthopedics and Musculoskeletal Science, United Kingdom, ⁴Northwick Park Institute for Medical Research,Yeovil District Hospital NHS Foundation Trust: Yeovil, GB, United Kingdom

Aims: Minimally invasive Surgical (MIS) techniques are considered the gold standard of surgical interventions but entail high environmental cost due to anaesthetic greenhouse gases, disposable instrumentation and energy use. The European Union is the third largest healthcare CO2 emitter in the world. With global temperatures rising and unmet surgical needs persisting, this review aims to investigate the carbon and material footprint of MIS operations and summarizes strategies to make MI surgery greener.

Methods: The MEDLINE, Embase and Web of Science databases were interrogated between 1974 and July 2021. The search strategy encompassed terms for the surgical setting, waste, carbon footprint, environmental sustainability, and minimally invasive surgery. Two independent investigators performed abstract and full text reviews. Carbon footprint studies were evaluated using a 34-item checklist based on the Greenhouse Gas (GHG) Protocol to identify processes contributing to carbon emissions that are commonly insufficiently investigated.

Results: From the 2,456 abstracts identified, sixteen studies were selected reporting on 5,203 MIS procedures. GHG emissions ranged from 6 to 814 kg CO2e per case. Carbon footprint hotspots included production of disposables and anaesthetics, followed by energy use and disposal. Combination of propofol anesthesia, minimal instrument operations and maximum reuse decrease the carbon footprint. On evaluation, 3/6 studies accounted for less than half of the GHG emitting processes on the checklist. Processes reported in 2 studies or less included capital equipment manufacturing, water processing, disposal of reusables, production of anaesthetic gases and surgical supplies. The material footprint of MIS varied from 0.25 kg to 14.3 kg per case. Strategies to reduce waste included replacing endoscopic staplers with polymeric clips, repackaging of disposables, limiting open unused instruments and educational interventions. Robotic procedures were linked with 43.5% higher GHG emissions and 24% higher waste production than laparoscopic alternatives.

Conclusion: Current MIS practice contributes to GHG emissions through production of disposables, anesthetic gases, energy use and disposal. Carbon and waste hotspots differ by operation and setting with higher environmental impacts attributed to robotic techniques. Further collaborative efforts are required focusing on standardized life cycle assessments to identify effective interventions that will improve the environmental sustainability of MIS.

ROBOTICS & NEW TECHNIQUES—Education

O135—The Development of Visuospatial Abilities and their Impact on Laparoscopic Skill Acquisition: A Clinical Longitudinal Study

Emina Letić ¹, T. Vajsbaher², H. Schultheis², S. Janssen³, D. Weyhe³, H. Bektas⁴, V. Uslar³

¹Facutly of medicine University of Sarajevo, Department of Surgery, Bosnia-Herzegovina, Facutly of medicine University of Sarajevo, Bremen Spatial Cognition Center, Germany, ²University of Bremen, Bremen Spatial Cognition Center, Germany, ³University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Carl von Ossietzky University Oldenburg, Visceral Surgery, Germany, ⁴Klinikum Bremen-Mitte, Department for General, Visceral-and-Surgical Oncology, Germany

Objectives: To investigate how visuospatial abilities develop and influence intraoperative laparoscopic performance during surgical residency training programmes.

Background: Laparoscopic surgery is a challenging technique to acquire and master. Visuospatial ability is an important attribute but most prior research have predominantly explored the influence of visuospatial abilities in lab-based settings and or among inexperienced surgeons. Little is known about the impact of visuospatial profiles on actual laparoscopic performance and different levels of expertise and its role in shaping competency.

Method: A longitudinal observational cohort study using a pair-matched design over 27 months. At baseline, visuospatial profiles of 43 laparoscopic surgeons of all expertise levels and 19 control subjects were compared. The development of visuospatial abilities and their association with intraoperative performance of 18 residency surgeons were monitored during the course of their laparoscopic training.

Results: Laparoscopic surgeons significantly outperformed the control group on the measure of spatial visualisation (U = 273.0, p = 0.03, η² = 0.3). Spatial visualisation was found to be a significant predictor of laparoscopic expertise (R² = 0.70, F (1,60) = 6.788, p = 0.01) and improved with laparoscopic training (B = 4.01, SE = 1.83, p = 0.02, 95% CI [0.40, 7.63]). From month 6 to 18 a strong positive correlation between spatial visualisation and intraoperative depth perception (r = 0.67, p < 0.01), bimanual dexterity (r = 0.60, p < 0.01), autonomy (r = 0.78, p < 0.01) and the total score (r = 0.70, p < 0.01) were observed but a strong relationship remained only with autonomy (r = 0.89, p < 0.01) and total score (r = 0.80, p < 0.01) at 18 months.

Conclusion: Visuospatial abilities associate with laparoscopic skills and improve with training. Spatial visualisation may be characteristic of laparoscopic expertise as it has clear association with competency development during laparoscopy residency training programme.

Fig. 1 A graphical illustration of the spatial visualisation trajectory per cohort group over the 27-month

ROBOTICS & NEW TECHNIQUES—Technology

O136—Ensuring Privacy Protection in the Era of Big Laparoscopic Video Data: Development and Validation of an Inside Outside Discrimination Algorithm (IODA)

Andre Schulze ¹, D. Tran¹, S. Bodenstedt², M.T.J. Daum¹, S. Speidel², M. Wagner¹, B.P. Müller¹

¹Heidelberg University Hospital, General, Visceral and Transplantation Surgery, Germany, ²National Center for Tumor Diseases Dresden, Translational Surgical Oncology, Germany

Aims: The purpose of this study was to ensure data privacy in video recordings of laparoscopic surgery by censoring extraabdominal parts that may identify patients or personnel. To achieve this objective, different computer vision algorithms were developed and validated to discriminate between inside and outside positioning of the laparoscopic camera.

Methods: The algorithms were based on deep neural networks, some of them including a recurrent Bayesian neural network modeled with probability distributions so that previous frames can influence the prediction of the following frames. Due to the fact that outside classes are not as prevalent as the inside classes, we used a probabilistic metric to quantify the uncertainty of the algorithm’s predictions. Eight experiments with the following combinations of parameters were carried out: ordinary deep neural network vs. Bayesian neural network, penalized vs. non-penalized class imbalance, and training on the binary classes (inside, outside) vs. training on five annotated subclasses (inside, translucent trocar, trocar, outside for cleaning, outside). Operation videos were divided into four main categories: upper gastrointestinal, cholecystectomy, colorectal and miscellaneous. A medical expert carried out the data annotation using the annotation software Anvil. In particular, the model’s false but highly certain predictions were penalized. For algorithm training five equally sized sets of 20 videos were formed and alternated to form the training and test sets. To ensure the sets are homogeneous in total video length and operation types, the original data set was manually divided.

Results: The data set contained a total of 100 laparoscopic surgery videos of 23 different operation types recorded at the Heidelberg University Hospital with a total video length of 170 h (102 min ± 85 min per video) resulting in 18.507.217 frames. The best results for all metrics were achieved by the penalized Bayesian network trained on all subclasses. The F1-score was 0.62 ± 0.02, accuracy was 0.90 ± 0.00, and false negative rate (outside wrongly annotated as inside) was 0.08 ± 0.01.

Conclusion: The penalized Bayesian network trained on all subclasses is able to discriminate between inside and outside with a high certainty. In particular, due to a low false negative rate only a few outside frames are misclassified as inside. This is critical to prevent identification of patients and personnel in the censored video. A potential application of the algorithms is the building of a laparoscopic video database while ensuring privacy protection. These anonymized videos can then be used for quality management, for high impact research or even for educational purposes. Although there are commercial solutions which are able to discriminate between inside and outside of laparoscopic videos, the major disadvantage of proprietary software is that they are expensive and not open source, meaning they can not be improved by the scientific community.

ROBOTICS & NEW TECHNIQUES—Technology

O137—Surgical Workflow Analysis and Full Scene Segmentation in Laparoscopic Cholecystectomy—Results of the HeiSurf Machine Learning Challenge 2021

Marie Theresia Julia Daum ¹, J. Chen¹, S. Bodenstedt², B. Müller¹, R. Younis¹, P. Petrynowski¹, T. Davitashvili¹, M. Raddatz¹, A. Kisilenko¹, L. Maier-Hein³, S. Speidel², F. Nickel¹, B.P. Müller-Stich¹, M. Wagner¹

¹Heidelberg University Hospital, General, Visceral and Transplantation Surgery, Germany, ²National Center for Tumor Diseases Dresden, Translational Surgical Oncology, Germany, ³German Cancer Research Center Heidelberg, Division for Computer-Assisted Medical Interventions, Germany

Aims: Analysis of laparoscopic video using machine learning methods is a potentially valuable tool for early detection and prevention of undesired intraoperative events in minimally invasive surgery. For example, detecting the cystic duct in cholecystectomy may help with the critical view of safety. To provide accurate detection in the future, we present results of an international machine learning challenge on laparoscopic cholecystectomy.

Methods: The data consists of 33 anonymized laparoscopic cholecystectomies from the HeiChole Benchmark data set, including video phase segmentation, instrument presence detection, and action recognition. In addition, full scene segmentation of 22 image classes (e.g., gallbladder, cystic duct) was performed for 827 images by three independent annotators each. Results were validated by a board-certified surgeon. The annotators utilized the open-source Computer Vision Annotation Tool (CVAT). The resulting data set was made available for the HeiSurf challenge, part of the Endoscopic Vision Challenge 2021 (https://www.synapse.org/#!Synapse:syn25101790/wiki/608802), in which 11 international research groups competed with their machine learning algorithms.

Results: The HeiSurF data set contains 33 videos totaling 23.3 h, yielding 827 annotated images. For full scene segmentation, an F1 score up to 57.5% was achieved (n = 8 teams), for phase segmentation up to 70.3% (n = 7 teams), for instrument presence up to 72.9% (n = 6 teams), but only 30.7% for action recognition (n = 5 teams). Compared to the 2019 Endoscopic vision challenge winners, this shows a marked improvement of F1 scores with up to + 4.9% for phase segmentation, + 9.1% for instrument presence, and + 7.4% for action recognition.

Conclusions: Full scene segmentation of laparoscopic images allows for identifying risk structures, which aids the development of artificial intelligence and cognitive robots to support minimally invasive surgery. However, the robustness of algorithms is not yet sufficient for clinical use. However, as these algorithms may be used for early detection of undesired events and accurately predict adverse outcomes in the future, the creation of fully segmented open data sets is an essential step towards increased patient safety.

ROBOTICS & NEW TECHNIQUES—Technology

O138—Knowledge Transfer of a Deep Neural Network in automated Phase Recognition from Sleeve Gastrectomy to Minimally Invasive Esophagectomy

Jennifer Aylin Eckhoff ¹, Y. Ban¹, G. Rosman¹, D.A. Hashimoto¹, E. WItkowski¹, D.T. Müller², D. Rus³, C.J. Bruns², H.F. Fuchs², O. Meireles¹

¹Surgical Artificial Intelligence and Innovation Laboratory, MGH, Surgery, USA, ²Universitätsklinikum Köln, Germany, ³CSAIL, MIT, USA

Objectives: To evaluate the feasibility of machine learning knowledge transfer across different surgical procedures using a previously described deep residual neural network (SleeveNet) in phase recognition from sleeve gastrectomy to the laparoscopic steps of Ivor-Lewis esophagectomy and to assess its overall performance.

Background: Surgical phase recognition by means of computer vision presents an important requirement for AI assisted understanding of surgical workflow. Phase recognition has been demonstrated on various procedures. Its performance is heavily dependent on the quality of annotations, which are time consuming and not always suitable to train on datasets of new procedures. Knowledge transfer of a previously established convolutional neural network has the potential to leverage annotations from common procedures and subsequently recognize similar procedural steps in other, more complex operations, therefore promoting data efficiency. Adequate surgical video data remains a limiting factor in the development of surgical AI, especially with regard to rare and highly specialized procedures such as esophagectomy. To improve generalizability, phase recognition models trained on large, readily available datasets may subsequently be extrapolated and transferred to smaller datasets of different procedures.

Methods: In this study, we defined the operative steps of the abdominal part of Ivor-Lewis esophagectomy in esophageal cancer patients through consensus of a small expert focus group of 3 board certified surgeons. A small dataset of 20 esophagectomy videos were annotated according to the defined phases by trained upper GI surgeons. We then assessed transfer learning capability of a previously trained and validated deep neural network from laparoscopic sleeve gastrectomy to laparoscopic esophagectomy. Different training/testing splits were used to evaluate model performance: a) only esophagectomy (train: 10/ test: 10) b) mixed training set (train: 55 sleeves and 10 esophagectomies/test: 10 esophagectomies) c) sleeve only (train: 55 sleeve/test 10 esophagectomies).

Preliminary Results: The operative phases of abdominal esophagectomy were determined as: 1. Port placement 2. Liver retraction 3. Mobilization of lesser curvature and lymphadenectomy 4. Dissection of left gastric artery 5. Exposure of right crus 6. Dissection of Gastrocolic Ligament 7. Exposure of left crus 8. Mediastinal dissection 9. ICG test 10. Stapling of conduit. Overall model accuracy for phase recognition was 70% throughout all training/testing splits. When trained on both procedures compared to only being trained on esophagectomies the model showed slightly improved accuracy on operative phases with high procedural overlap, such as “Dissection Gastrocolic ligament” (92 vs 90% accuracy). Based on our hypothesis, the model showed reasonable accuracy when trained merely on sleeve gastrectomy and tested on esophagectomy (84% for “Dissection Gastrocolic ligament”).

Conclusion: Robust phase recognition models can achieve reasonable accuracy in knowledge transfer from one procedure to another even when exposed to small datasets. Further exploration is required to determine appropriate data amounts and key characteristics of the target procedure required for transferal phase recognition. Transfer learning with phase recognition models across different procedures addressing small datasets may increase data efficiency. Finally, to enable surgical application of AI for intraoperative risk mitigation coverage of rare, specialized procedures needs to be explored.

ROBOTICS & NEW TECHNIQUES—Education

O139—Virtual Reality Head Mounted Display versus Three-dimensional Models and Two-dimensional Tomography Display for Training of Liver Surgery—A Randomized Controlled Study

Philipp Anthony Wise ¹, F. Nickel¹, A.A. Preukschas¹, L. Bettscheider¹, S. Speidel², M. Wagner¹, M. Pfeiffer², M. Huber³, M. Golriz¹, F. Fischer⁴, A. Mehrabi¹, B.P. Müller-Stich¹

¹University Hospital Heidelberg, General, Visceral and Transplant Surgery, Germany, ²National Centre for Tumor Diseases, Department for Translational Surgical Oncology, Germany, ³Karlsruhe Institute of Technology, Department for Anthropomatics and Robotics, Germany, ⁴Hospital Mittelbaden, Department of Surgery, Germany

Objective: Evaluation of the benefits of a virtual reality (VR) environment with a head-mounted display (HMD) for decision-making in liver surgery.

Background: Training in liver surgery involves appraising radiologic images and considering the patient’s clinical information. Accurate assessment of 2D-tomography images is complex and requires considerable experience, and often the images are divorced from the clinical information. We present a comprehensive and interactive tool for visualizing operation planning data in a VR environment using a head-mounted-display and compare it to 3D-visualization and 2D-tomography.

Methods: 90 medical students were randomized into 3 groups (1:1:1 ratio). All participants analyzed three liver surgery patient cases with increasing difficulty. The cases were analyzed using 2D-tomography data (group “2D”), a 3D-visualization on a 2D display (group “3D”) or within a VR-environment (group “VR”). The VR environment was displayed using the “Oculus Rift TM” HMD technology. Participants answered 11 questions on anatomy, tumor involvement and surgical decision making and 18 evaluative questions (Likert scale).

Results: Sum of correct answers were significantly higher in the 3D (7.1 ± 1.4, p < 0.001) and VR (7.1 ± 1.4, p < 0.001) groups than the 2D group (5.4 ± 1.4) while there was no difference between 3D and VR (p = 0.987). Times to answer in the 3D (6:44 ± 02:22 min, p < 0.001) and VR (6:24 ± 02:43 min, p < 0.001) groups were significantly faster than the 2D group (09:13 ± 03:10 min) while there was no difference between 3D and VR (p = 0.419). The VR environment was evaluated as most useful for identification of anatomic anomalies, risk and target structures and for the transfer of anatomical and pathological information to the intraoperative situation in the questionnaire.

Conclusions: A VR environment with 3D visualization using a HMD is useful as a surgical training tool to accurately and quickly determine liver anatomy and tumor involvement in surgery.

ROBOTICS & NEW TECHNIQUES—Technology

O140—Step-by-Step Guide to Spacial Annotation of Robotic Tools: Stumbling Stones and Valuable Insights from Two European Expert Centers

Pieter De Backer ¹, J.A. Eckhoff², D. Müller³, B. Babic³, C. Allaeys¹, H. Creemers¹, A. Hallemeesch¹, C. Bruns³, A. Mottrie¹, H.F. Fuchs³

¹University Hospital of Zurich, Department of Surgery, Switzerland, ²University Hospital of Zurich, Department of Radiology, Switzerland, ¹ORSI Academy, Urology, Belgium, ²Surgical Artificial Intelligence and Innovation Laboratory, Surgery, USA, ³Universitätsklinikum Köln, Surgery, Germany

Objective: Instrument detection is one of the major building blocks for the implementation of artificial intelligence in surgery. Through supervised learning, state of the art machine learning models are capable of identifying and tracking endoscopic instruments. This requires previous manual annotation of video frames for the algorithm to extract features from, which is time consuming and lacks standardization. Readily annotated publicly available surgical datasets serve as sources for new algorithms and are key to the advancement of AI in surgery. However, they are limited in size and diversity, covering merely procedures with limited complexity and variability such as cholecystectomy, gastric surgery and colectomies. Besides lacking standardization of laparoscopic procedures, instrument annotations of robotic surgeries and standardization of such have been entirely neglected in the past. Robotic video frames generally contain more instruments with more complex features (see Fig. 1), hence annotation has to be addressed separately. We present a primary exploration of the annotation of robotic instruments. Subsequently we demonstrate the transferability between procedures and building on that we will propose an annotation guideline for robotic surgery in the future.

Technology: Given the need for a standardized surgical annotation guideline in laparoscopic as well as robotic procedures, we present lessons learned from annotating 70 robotic assisted partial nephrectomies (RAPN) and show the transferability to robotic assisted esophagectomy (RAMIE).

Preliminary results: Annotation of robotic instruments presented extremely time consuming (average in minutes: vector: 3 min, pixel: 6 min), especially with regard to repetitive annotation of the same instrument when using the same class (e.g. clips). One way to improve efficiency is the differentiation between instance and semantic segmentation. The application of different labels per clip as in Fig. 2b allows for easy differentiation between individual objects later on and enables conversion from instance segmentation to semantic segmentation. Another insight gained from this exploration is that tissue obstructing the full view of an instrument should be spared from annotation, for higher accuracy of the later applied computer vision model, which extracts direct visual information rather than applying human-like interpretation. Another useful feature is the application of bounding boxes. We found that annotation using bounding boxes is less time consuming, however is more open to interpretation and hence less specific. A more accurate approach to annotate instrument direction is to delineate the instrument in a precise manner and retrieve the bounding box from the resulting segmentation, as can be seen in Figure.

Conclusions & future directions: Given the fact that the performance of a model directly correlates to the quality of the input data, a concise and structured approach to annotating images is primordial to enable computer vision techniques in surgery. To our knowledge, no exact guidelines exist for annotation of robotic instruments in order to start an AI powered surgical analysis program. We propose a time-saving and high quality framework for annotating robotic surgery images, and show the transferability between two procedures (RAPN and RAMIE) through lessons learned in two European high volume robotic expert centers.

ORAL PRESENTATIONS

AMAZING TECHNOLOGIES

O001—Evaluation of the Novel Veress Needle + Mechanism; A Pre-clinical Study on Thiel-Embalmed Bodies

Roelf Postema ¹ , S. Hardon¹, D. Cefai², J. Dankelman³, F.W. Jansen⁴, C. Camenzuli⁵, J. Calleja-Agius⁵, T. Horeman-Franse⁶

¹Amsterdam UMC, Surgery, The Netherlands, ²Provinci Medtech, Engineering department, The Netherlands, ³Delft University of Technology, Biomechanical Engineering, The Netherlands, ⁴Leiden University Medical Centre, Gynaecology, The Netherlands, ⁵University of Malta, Deaprtment of Anatomy and Surgery, Malta, ⁶Delft University of Technology, Biomechanical Engineering, The Netherlands

Background: The use of the Veress needle (VN) is commonly used in establishing pneumoperitoneum in laparoscopic surgery. However, severe vascular and/or visceral complications can occur due to overshoot at insertion of the needle in the abdominal cavity. A VN with a new safety mechanism (VN +) was developed to reduce the amount of overshoot. The VN + was tested and compared to the conventional Veress needle (VNc) on Thiel embalmed bodies as a pre-clinical investigation.

Methods: 18 participants (novices, intermediates and experts) performed in total 248 insertions in a systematic way with wide and small bore versions of the conventional VNc and the VN + . Questionnaires were used to get user feedback on the bodies and VN +. Insertion depth was measured by recording the graduations on the needle under direct laparoscopic vision (Fig. 1).

Results: Participants graded the bodies and the procedures as lifelike. Overall, a significant reduction (p < 0.001) in average insertion depth was found for the VN + compared to VNc of 26.0 SD16 mm vs 46.2 SD15 mm. The insertion depth difference in the novice group was higher compared to the intermediates and experts (p < 0.001). No difference was observed between the two bodies and the different bore diameters. The average insertion depth for both the VNc and VN + was significantly less (p < 0.001) performed by female participants compared to male. The regression analysis indicated no wear- or learning curve effects (Fig. 2).

Conclusion: In line with preliminary in vitro results, this study indicated that the VN + significantly reduced the insertion depth in all tested conditions. Whether the difference between female and male performance may be linked to differences in muscle control or arm mass should be further investigated. Useful technical information was gathered from this study to further improve the VN + .

AMAZING TECHNOLOGIES

O002—Game-Inspired Portable and Cost-Effective Virtual Simulation for Flexible Endoscopy

S. Perretta¹, Pietro Riva ¹, R. Bessard-Duparc², S.Piant³, D. Van As⁴, S. Stramigioli⁵, S. Cotin⁶, S. Van Den Dool⁷

¹IRCAD France, Surgery, France, ²INRIA, MIMESIS, France, ³IHU, Education, France, ⁴University of Twente, France, ⁵University of Twente, RAM, France, ⁶INRIA, MIMESIS, France, ⁷TVH business consultancy, France

Background: Flexible endoscopy is a minimally invasive technique that requires intensive training to master the complex hand-eye coordination. Its advantages in terms of patient comfort and promptness of diagnosis have made it attractive to many physicians and surgeons. Geographical and financial accessibility doesn’t allow a homogeneous access to training limiting its potential diffusion. Within a research project led by institutes expert in minimally invasive surgery (IHU Strasbourg, IRCAD-France), simulation (INRIA Strasbourg), and hardware interfaces (Twente University), we have developed a new type of portable and attractive simulator using serious game type interfaces.

Aims: To present a portable and affordable virtual simulator for the training of basic skills in flexible endoscopy.

Method: We 3D-printed a real size endoscope that can be connected to a computer with a plug'n'play standard, allowing a realistic interaction via knobs and buttons. This hardware controls a real-time physics-based simulation reproducing an endoscope and its interactions with the virtual anatomy (assessed with real clinical data). The use of underwater gaming graphics was key to help trainees learn endoscopic skills while playing an immersive and motivating game. Accessibility and deployment are ensured by cloud streaming technology allowing students to train at their own pace on their laptop (Fig. 1). The simulator was presented to beginners and experts (> 100 endoscopies/year) during training workshops in flexible endoscopy. We collected a questionnaire during each session.

Results: Trainees (n = 114, 90 beginners, 24 advanced) rated the interface as attractive and well adopted (mean 4,5/5 (SD 0.73)); easy to use without supervision (4,6/5, (1.2)) and well balanced between training (1) and game (5) with a score of 3.5/5 (0.67). There was no statistical difference between the beginners and advanced sub-groups results.

Conclusion: We developed a novel and affordable training system for flexible endoscopy consisting of a dedicated hardware and a physics-based simulation virtualizing endoscope movements and its interactions. We introduced a “disruption” in the visualization, which increases engagement of the trainee, and use of internet-based assets to ensure access anywhere, anytime. The simulator has been well perceived by trainees and a validation study to demonstrate the educational potential of this simulator is ongoing.

Keywords: Simulation, Physics, Surgery, Endoscopy, Training

AMAZING TECHNOLOGIES

O003—Quantitative Mechanical Assessment of 3D Printed Vessels for Suture Training and Simulation

Valeria Mauri ¹ , E. Negrello¹, L. Pugliese², A. Peri², A. Pietrabissa², F. Auricchio¹, S. Marconi¹

¹University of Pavia, Civil Engineering and Architecture, Italy, ²Fondazione IRCCS Policlinico San Matteo of Pavia, General Surgery II, Italy

Vessels anastomosis is one of the most challenging tasks to learn in all surgical fields: on one hand surgeons have to acquire extended experience in the technical gesture and the involved instrumentation; on the other hand it is also necessary they adapt the movements and the exerted force according to the specific vascular structure that is being treated. In this context, surgical simulation is gaining a pivot role in the training of surgeons but can rely, however, only on standard and simplified anatomies which not include any patient-specific or pathological feature. In this sense, 3D printing (3DP) technology allows the manufacturing of extremely complex geometries, thus perfectly suitable for producing realistic replica of patient-specific anatomies. While morphological aspects can be easily handled, the reproduction of tissues mechanical properties poses major problems: to date, available 3DP materials are still quite limited in mimicking biomechanical properties of soft tissues, thus limiting the possibility of using 3D printed models for simulation purposes.

Among 3D printing materials, photopolymers are the most promising class: through Material Jetting technology it is possible to mix photopolymers, allowing a fine tuning of the final object’s mechanical properties. The present work focuses on the identification—through both qualitative and quantitative tests—of the 3D printing materials’ combination able to best mimic blood vessels’ mechanical properties during anastomoses. A J750TM Digital AnatomyTM 3D Printer and commercial photopolymers from Stratasys® where selected for this purpose.

Puncture tests and stitch traction tests [Fig. 1] were performed—using an ad hoc experimental set-up—to evaluate and quantify the mechanical properties of the different photopolymer mixtures namely puncture force and materials’ resistance to the stitch respectively. From preliminary tests, the selected surgical thread is a Prolene 5/0 while all mechanical tests were performed through a MTS Insight Testing System® with a 250 N load cell. The same mechanical tests were performed also on porcine aorta samples, to be used as a biological comparison.

The best mixes were then used to 3D print some patient-specific vascular models on which an expert surgeon performed realistic anastomoses in order to validate the results of samples’ mechanical characterization tests [Fig. 2].

A total of 37 experimental photopolymer mixtures were tested. 6 material combinations were selected as a final pool to be subjected to 10 repetitions for each mechanical test type, for a total of more 120 mechanical tests performed. Finally, among them, 2 formulations were selected as the most promising in order to mimic different blood vessels for anastomoses surgical simulation and were used to 3D print patient-specific vessels to be used as validation models.

The first one was selected as the most suitable option to replicate medium strength vessels, as aortic arch or thoracic aorta; while the second one best mimic more subtle vessels—namely abdominal aorta or minor branches.—mechanical properties.

In conclusion, both photopolymer mixes and samples’ thickness has been proven to be the main parameters to tune in order to obtain realistic vessels’ replica for simulation purposes.

AMAZING TECHNOLOGIES

O004—ProHep-LCT Robotic System for the Intraoperative Targeted Treatment of Non-resectable HCC Tumours

D. Pisla¹, Emil Mois ¹, N. Al Hajjar², N. Plitea³, F. Graur², C. Vaida³, C. Radu⁴, I. Birlescu³, B. Gherman³, P. Tucan³, C. Popa⁴, E. Mois⁴

¹Regional Institute of Gastroenterology and Hepatology, Robotic Department, Romania, ²Regional Institute of Gastroenterology and Hepatology, General Surgery Department, Romania, ³CESTER, Technical University of Cluj-Napoca, Robotic Department, Romania, ⁴Regional Institute of Gastroenterology and Hepatology, Gastroenterology Department, Romania

Purpose: to analyse the feasibility (in laboratory conditions) of ProHep-LCT, a dual-arm parallel robotic system, for the intraoperative targeted treatment (using brachytherapy or intratumoral chemotherapy) of hepatocellular carcinoma (HCC) using real-time ultrasound guiding for the therapeutic needle.

Materials and Methods: a phantom gel of a human liver was created with simulated internal structures for blood vessels and tumours, and ProHep-LCT master-slave robot was used to insert needles into the phantom targeting a tumour under real-time monitoring using intraoperative ultrasound (IUS). The dual-arm robotic system (Fig. 1) was designed to manipulate independently two separate devices using custom designed end-effectors, one carrying an intraoperative ultrasound probe and the other a device that can carry up to six needles that can be inserted on parallel (or independent) trajectories based on a pre-planning program or using on-site defined coordinates. In our experiment, the surgeon operated (from the master control console) the IUS probe using one robotic arm of ProHep-LCT. After the tumour was localized, the second robotic arm of ProHep-LCT automatically positioned the needle on a trajectory defined by two points (an insertion point and a target point) specified by the surgeons in the control interface. The needle was inserted on a linear trajectory until the defined target point under real-time imaging using IUS.

Results: a total of 10 experimental trials were made, 5 tumour formations (with diameters of 5 and 10 mm) were targeted for the needle insertion, each with two insertion trajectories. In 80% of the experimental trials, the tumour was correctly targeted with a positioning accuracy of less than 2 mm; in 20% of the experimental trials, the tumour was hit but a positioning error of 3.4 mm (± 1.2 mm).

Conclusions: ProHep-LCT robotic system can provide new approaches for the targeted treatment of non-resectable HCC tumours, but further research, improvements, and laboratory tests are required to demonstrate the feasibility, safety, and ergonomics of the proposed technology.

Acknowledgement: This work was supported by a grant of the Ministry of Research, Innovation and Digitization, CNCS/CCCDI—UEFISCDI, project number 397PED—OnTarget, within PNCDI III.

AMAZING TECHNOLOGIES

O005—Clinical translation of a novel, dye-free perfusion imaging technique in minimally invasive surgery

Wido Heeman ¹, E.C. Boerma²

¹UMCG, Surgery, The Netherlands, ²Medical Center Leeuwarden, Intensive Care, The Netherlands

Organ perfusion has been of interest to surgeons unremittingly as it is generally understood that adequate tissue perfusion is related to reduced morbidity and mortality. Current indicators of tissue viability are bleeding of the resected edges, palpable pulsations of arteries and tissue color. However, these subjective clinical indicators rely heavily on the surgeons’ experience lacking objectivity and reproducibility of results between surgeons. A promising objective imaging method that can provide objective and reproducible perfusion imaging is called laser speckle contrast imaging. For this study, a dye-free, instantaneous, continuous and real-time laparoscopic perfusion imaging device called PerfusiX-Imaging® (LIMIS Development BV, Leeuwarden, The Netherlands) was used. This device uses low powered laser light to generate perfusion images (Fig. 1). This technique was first validated using the classical ischemia reperfusion experiment on the human nail fold, porcine small intestine and porcine kidney (Fig. 2A–D). The sub-surface perfusion measurement on the kidney was simultaneously imaged and compared with a gold standard microscopy perfusion imaging technique. The high correlation between both imaging modalities confirms that laser speckle measures sub-surface perfusion. PerfusiX-Imaging® has shown the ability to detect very subtle perfusion differences in both temporal and spatial analysis. Clear watershed areas could be identified on the kidney and small intestine suggesting potential for clinical application in gastro-intestinal and transplantation surgery. A comparison with local capillary lactate levels indicate that the PerfusiX-Imaging perfusion units are linked to an ischemic biomarker. After validation of the technique, to investigate the potential clinical added value, a multi-center study was performed to investigate the surgeons’ interpretation of the PerfusiX-Imaging perfusion images (Fig. 2E–F). All imaging procedures were successful with little interruption of the surgical workflow of only 3 min on average. The low inter-operator variability shows promise for this device as this indicates that, even though this is a qualitative measurement, the surgeons’ collective judgement is rather objective. The basic and fundamental (pre-)clinical studies provide evidence that PerfusiX-Imaging® is capable of measuring the slightest of perfusion differences in real-time. When this technology is combined with a standardized and reproducible imaging procedure it can yield reliable perfusion measurements. Finally, the clinical value in minimally invasive surgery has yet to be determined in an intervention study.

AMAZING TECHNOLOGIES

O006—Surgical Audio Guidance: A Vibroacoustic-Based Solution for Supporting Veress Needle Placement during Laparoscopic Access

Nazila Esmaeili ¹ , M. Spiller¹, T. Sühn¹, A. Boese², A. Gumbs³, M. Friebe¹, A. Illanes¹

¹SURAG Medical GmbH, Research and Development, Germany, ²Otto-von-Guericke University Magdeburg, Medical Faculty, Germany, ³Centre Hospitalier Intercommunal de Poissy/Saint-Germain-en-Laye, France

Aims: Minimally invasive surgery including laparoscopic, endoscopic, and robotic surgery has brought a wide range of advantages for the patients and surgeons. Nevertheless, it has limited the natural senses that surgeons mainly used during traditional open surgery. Surgical Audio Guidance (SURAG) is a novel sensing technology that utilizes vibroacoustic (VA) waves resulting from any interactions between the surgical instrument tip and tissue and allows magnifying relevant aspects of these interactions like tissue-tissue passage in real-time. In this study, we aim to demonstrate the potential of the SURAG system in providing understandable and interpretable guidance information during Veress needle insertion in laparoscopic access procedure.

Methods: SURAG system was used to acquire VA waves during Veress needle insertion on 9 non-living pigs. The system has two main components: first, SURAG add-on sense that was connected to the proximal end of a Veress needle via the standard Luer-lock mechanism and measured the VA waves originating from the tissue-needle's tip interaction. Second, SURAG feedback that received these VA signals wirelessly and stored them in internal storage. It also provided a real-time display of the VA signal along with real-time processed audio that magnified the VA signals. After needle insertion, a standard drop test was performed to confirm cavity targeting, and the information was used as ground truth for the VA wave analysis.

Results: A total of 192 VA signals were acquired and analyzed using advanced signal processing techniques. Both time-domain and frequency-domain parametrization of the events in VA signals showed that all the necessary information for identifying and magnifying fascia and peritoneum cavity punctures are presented. Moreover, the features related to dynamical characteristics of these events can be used for the automatic classification of them using Artificial-Intelligence-based methods for future applications.

Conclusion(s): The SURAG system has shown its potential to provide real-time feedback for peritoneum cavity targeting during Veress needle insertion. The system can be connected to any type of Veress needle, has no active components in direct contact with patients, and does not change the surgical workflow.

AMAZING TECHNOLOGIES

O007—Reliable Anonymization of Robotic Surgical Video Data using Deep Learning

Pieter De Backer ¹ , J.A. Eckhoff², D. Müller², F. Cisternino³, F. Ferraguti³, S. Vermijs⁴, C. Debbaut⁴, C. Van Praet⁵, K. Decaestecker⁵, A. Mottrie¹, H. Fuchs²

¹Orsi Academy, Urology, Belgium, ²Uniklinik Cologne, General Surgery, Germany, ³University of Modena, Italy, ⁴Ghent University, Biommeda, Belgium, ⁵Ghent University Hospital, Urology, Belgium

Aims: Over the last years, surgical video analysis has become increasingly important for teaching, education and performance evaluation. One bottleneck in this analysis is the sharing of these videos between surgical centers and research entities due to the need for reliable anonymization to comply with legal and ethical standards across the world. This includes removal of video parts capturing images outside of the body. These parts might reveal the identity of the patient or surgical team and hence violate privacy regulations. High volume centers and specialized research institutions frequently rely on corporate software for anonymization of surgical video data and removal of said “out of body images”. We propose a novel algorithm of automatically blurring these parts by the use of artificial intelligence and show its reliable performance and transferable application on two different, highly complex robotic surgeries.

Methods: First, an established deep learning convolutional neural network (Resnet18) is trained to classify images as inside or outside of the body in 44 robot-assisted partial nephrectomies (RAPN) cases. The training dataset consists out of 9263 images annotated as “inside body” and 278 images annotated as “outside body”. The network’s performance is then evaluated in a validation set, composed of 550 “inside body” images and 42 “outside body” images. Training was performed on a desktop computer with 256 GB RAM with RTX3090 Nvidia GPU. Next, we evaluate the robustness of this unaltered ‘RAPN-network’ on a single robot-assisted minimal invasive esophagectomy (RAMIE) by manually checking all video frames after automated anonymization.

Results: The ‘RAPN-network’ achieves an accuracy of 99.92% on unseen images of partial nephrectomy. 321.212 frames of a RAMIE procedure were analyzed by the ‘RAPN-network’. On this completely new procedure, the ‘RAPN-network’ achieves an anonymization accuracy of 99.59%. No outside body frames were missed in the RAMIE anonymization (0 false negatives). The main portion of all 10.269 false positives consists out of ICG images, which might be considered a lookalike for surgical drapes as both have large amounts of green and black pixels. The main other five categories contributing to false positive anonymization include images with no instruments, images with high surgical smoke or insertions of a large gauze, images with endoscope occlusions due to trocar insertion and images with large instrument zoom on instruments or visualization of the surgeon’s hand.

Conclusion(s): We conclude that the proposed ResNet algorithm achieves reliable detection of out of body images when applied on the same procedural type. Furthermore, the algorithm is very sensitive and has a tendency to generalize well and anonymize broadly, resulting in robust deidentification of surgical video data for utilization in teaching and research. In order to further increase the model’s accuracy, further training on ICG enhanced images is needed. Future research should evaluate the generalizability to more RAMIE videos as well as other procedures, including laparoscopic and endoscopic video data.

AMAZING TECHNOLOGIES

O008—Human Xtensions (HX) is developing a hybrid system, HybridX, that combines the HandX, a hand-held steerable robotic device, with a mounted collaborative robotic (cobot).

Amir Szold ¹

¹Assia Medical Group, Surgery, Israel

HandX is a fully articulating 5 mm software-driven handheld device with changeable instruments, where the surgeon holds and moves the ergonomic handle to control the instrument and end-effector (such as a needle-holder, hook, etc.). The HybridX system connects this device to mounted robotic arms that can be controlled using a remote-control interface. This removes the fulcrum effect seen in basic MIS, making the surgery more instinctive and easier to learn. It may also reduces tremor given the stability of the robotic arm. The system can provide the ultimate flexibility—the surgeon can easily switch between laparoscopic and robotic surgery without the removal of instruments from the trocar. The HybridX can use any instrument on any arm and the OR staff can change instruments during a procedure. A video of a working prototype will be presented.

The system will include a sterile remote-control interface (RCI) to control the HandX and robotic arm with maximum flexibility for the user, allowing work inside or outside the sterile field, fully laparoscopically, fully robotically, or in a hybrid mode (one hand each) (Fig. 1). The intuitive RCI is capable of toggling control between multiple cobot arms, such as one holding a laparoscope and two with HandX devices, all controlled remotely by one surgeon. The improved ergonomics allow the surgeon to work while standing or sitting with weightless instruments. Furthermore, the system will be modular, consisting of separate carted cobot arms, enabling different hybrid configurations and optimizations to the surgeon’s needs and the hospital financial capabilities. These unique features can assist laparoscopic surgeons to easily adapt to the new hybrid surgery technology and take advantage of the benefits of both smart handheld and mounted tools.

AMAZING TECHNOLOGIES

O009—Real-Time Lumen Detection for Autonomous Colonoscopy with Semi-Supervised Learning

Baidaa Al-Bander¹, Manfredi Luigi ¹ , A.L. Mathew¹, L.U. Magerand², M.A. Trucco², L.U. Manfredi¹

¹University of Dundee, School of Medicine, Division of Imaging Science and Technology, United Kingdom, ²University of Dundee, School of Science and Engineering, Computing, United Kingdom

Aims: Colorectal cancer is the third most common cause of cancer death worldwide. Regular screening and early detection are vital to reduce mortality. Developing autonomous endorobots for bowel screening promises to increase the capacity of examinations and alleviate the drawbacks of the current optical colonoscopy, i.e., operator dependence and variation, high cost, and time required. Work on autonomous endoscopic navigation is emerging but has only been demonstrated in simple and specific environments, failing to provide sufficient evidence of clinical use. The unstructured and deformable nature of the colon imposes several challenges to traditional automated navigation strategies. We address this problem by presenting a colonoscope navigation strategy resilient to colon deformations.

Methods: Machine vision integrated with a deep learning approach is proposed to locate and track the colonic lumen under different challenging environments in real-time and robust against colon deformations. We use a large number of unlabelled frames in conjunction with only a few labelled frames from colonoscopy videos to effectively learn a semi-supervised deep learning model. For this semi-supervised learning technique, we adopt the mentor-student learning scheme. The proposed method is evaluated on comprehensive video data, including real colonoscopy, phantom, and synthetic videos.

Results: Experimental results confirms that the proposed approach is fast and reliable. It runs in real time at 60 ms/frame and achieves average precision of 96.25% and average recall of 66.95% using intersection over union threshold score of 0.5. In addition to quantitative evaluation, eight senior clinicians scored the accuracy of the automatic lumen detection for interventional purposes. The average accuracy score was 4.37 out of 5, indicating high perceived suitability for real colonoscopy.

Conclusions: Developing automated systems based on learning from vast amounts of unlabelled data would considerably decrease the labour of manual data annotations, thus reducing costs. The lumen detection and navigation approach presented here, exploiting only limited numbers of labelled data, can be utilised in colonoscopy and in general real-time endoscopic navigation tasks in deformable and unstructured settings.

AMAZING TECHNOLOGIES

O010—3-Year Results with an Implantable Device, Refluxstop, Treating Acid Reflux Without Compressing the Food Passageway

M. Bjelovic¹, László Harsányi ¹, L. Harsanyi², A. Altorjay³, Z. Kincses⁴, P. Forsell⁵

¹Euromedik Hospital, Department of Surgery, Serbia, ²Semmelweis University, Budapest, 1st Department of Surgery, Hungary, ³Fejér County Szent György University Teaching Hospital, Surgical Department, Hungary, ⁴University of Debrecen Kenézy Gyula Teaching Hospital, General Surgery Department, Hungary, ⁵Implantica, Switzerland

Background: RefluxStop™ is an implantable single use device used in the laparoscopic treatment of GERD to restore and maintain the LES with distance from the diaphragm hiatus, thereby keeping the angle-of-His in its original anatomical position, leaving the food passageway unaffected.

Methods: In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 3 years. Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction.

Results: No serious adverse events occurred between the post-surgical period and the 3-year Results: No device related adverse event occurred during the full study period and no device was explanted. The only adverse events reported between the 1- and 3-year results (1-year results previously published) were one subject with mild dysphagia and one with heartburn. No subject (0/47) took regular daily PPI at 3-years. Three subjects terminated the study during the first year, none of which took PPI at the time of termination. One subject (1/47) was dissatisfied for non-GERD reason (functional heartburn). GERD-HRQL score median reduction at 3-years was 93.1% since baseline. 24-h pH monitoring was normal in 98% of the patients at 6 months (44/45) and repeated at 3-years in the 4 subjects with < 50% improvement of the GERD-HRQL questionnaire and subjects taking PPI (without verified non-GERD reason), whereof 3/4 subjects were shown to have normal 24-h pH monitoring. One subject had pathologic pH and contrast swallow x-ray showing a too low position of the device, thereby at least partly prohibiting its function.

Conclusion: The implantable device RefluxStop™ presents a new principle of treating acid reflux without compressing or surrounding the esophagus. According to investigation results the device is safe and effective in treating GERD. At the 3-year follow-up, both the GERD-HRQL score, PPI usage and 24-h pH monitoring results indicate success for this new acid reflux treatment principle. In addition, with this dynamic treatment for acid reflux, side effects are reduced, such as reduced gas-bloating and dysphagia with only one subject having dysphagia at 3 years compared to 11 before surgery.

AMAZING TECHNOLOGIES

O011—Comparing Real-time Tissue Perfusion Assessment between Laser Speckle Contrast Imaging and Indocyanine Green Fluorescence in Porcine Small Intestine

Yao Liu ¹ , S. Mehrotra², V. Buharin³, J. Oberlin³, M. Marois³, C. Nwaiwu¹, M. Chand⁴, N. Bouvy⁵, L. Boni⁶, P. Kim³

¹Brown University, Surgery, USA, ²University of Buffalo, Surgery, USA, ³Activ Surgical, USA, ⁴University College London, Surgery, United Kingdom, ⁵Maastricht University, Surgery, The Netherlands, ⁶Department of Surgery Fondazione IRCCS—Ca' Granda—Ospedale Maggiore Policlinico—University of Milan, Surgery, Italy

Aims: Indocyanine Green Fluorescence Angiography (ICG-FA) permits intraoperative tissue perfusion assessment by detecting ICG dye in blood volume. Despite recent efforts to quantify ICG signal intensity, ICG-FA is inherently limited by dye diffusion, pharmacokinetics, and subjective interpretation. Laser Speckle Contrast Imaging (LSCI) aims to improve upon ICG by assessing real-time tissue perfusion without using dye and providing perfusion quantification using tissue benchmarks. Herein, we compare LSCI perfusion quantification against ICG-FA in a porcine intestinal model.

Methods: ActivSightTM (Activ Surgical, Boston, MA) is an FDA-cleared device combining LSCI and ICG fluorescence imaging in a laparoscopic form factor. LSCI detects real-time tissue blood flow by capturing coherent laser light scatter from red blood cells in microcirculation. A prototype LSCI feature quantifies tissue perfusion in relative perfusion units (RPU) as a percentage relative to perfused and ischemic reference tissue. A segment of porcine small intestine was devascularized, and vascular control was obtained via aortic inflow and portal venous outflow (Fig. 1A). Intestinal perfusion assessment was performed using LSCI (Fig. 1B) and ICG-FA (Fig. 1C).

Results: LSCI detects significant perfusion differences between the perfused and ischemic ends of small intestine—average RPU of ischemic vs. perfused halves of bowel was 17.0% vs. 60.5% (p = 8.38 × 10-11, Fig. 1D). ICG fluorescence reached saturation throughout the devascularized intestinal model over time with multiple dye injections and was unable to distinguish between perfused and ischemic intestine. LSCI also detects perfusion differences between mesenteric vs. antimesenteric sides of the bowel (p < .00001) and real-time perfusion deficits induced by both aortic/portal venous occlusions. Interestingly, LSCI detects intraluminal mucosal perfusion, and perfusion assessments of intestinal serosa versus mucosa were similarly concordant using LSCI.

Conclusions: LSCI provides real-time, quantifiable intestinal perfusion assessment with improved spatiotemporal specificity compared to ICG-FA. LSCI permits on-demand, repeatable tissue perfusion information that lacks false-positive perfusion signal in ischemic segments of intestine resulting from lapsed time or multiple dye injections. More objective intraoperative assessment of tissue perfusion using LSCI poses future opportunities for data-driven intraoperative decision support for surgeons.

AMAZING TECHNOLOGIES

O012—Novel device for anastomotic integrity assessment after left-sided colorectal resections

Giovanni Casella ¹ , L. Lidia¹, A. Iodice¹, A. Diddoro¹, M. F. Russo¹

¹Sapienza University of Rome, Department of Surgical Sciences, Italy

Background: Several methods have been described for the intraoperative evaluation of colorectal anastomotic integrity. Technological evolution has allowed to progress from basic mechanical methods, to the use of more sophisticated techniques including oxygen spectroscopy, Doppler flowmetry and fluorescence angiography of perianastomotic tissues. This study describes a novel endoluminal modality of colorectal anastomotic assessment through the use of a rigid scope introducer also allowing for intraoperative perfusion evaluation by indocyanine green (ICG) fluoroangiography in patients undergoing left-sided colorectal resection.

Methods: The Disposable Rigid Scope Introducer (DRSI) (Novadaq Technologies Inc., Burnaby, Canada) consists of an endoluminal introducer device made up of an insertion tube and insufflation port that enables attachment of a single-use insufflation bulb to manually insufflate the sigmoid and rectum. The DRSI is compatible with any laparoscopic camera, although, a laparoscope equipped with a fluorescence imaging system is highly recommended in order to perform fluoroangiography and assess tissue perfusion.

Results: The DRSI was successfully used to assess anastomotic integrity after all left-sided colorectal resections performed in 16 consecutive patients. The DRSI allowed to visualize the anastomotic site in all cases with a good or excellent quality of tissue perfusion by ICG-fluoroangiography. In 2 cases the DRSI showed the presence of significant anastomotic bleeding which was successfully controlled by laparoscopic suture placement. No loop ileostomy was performed after low rectal resections. No adverse event resulted from the use of this device.

Conclusions: The DRSI is able to combine the direct endoluminal visualization of the anastomosis together with a real time evaluation of its blood flow. This device holds great potential for a prompt intraoperative detection of anastomotic alterations, possibly reducing the risk of anastomotic leaks related to mechanical or perfusion issues.

Future Directions: The potential advantages of this device warrant larger cohort studies and prospective randomized trials. Future research should be directed at validating its safety and efficacy in possibly reducing colorectal leak rates also assessing its overall cost-effectiveness.

AMAZING TECHNOLOGIES

O013—Liver and Breast Complex Gelatin Based Phantoms Cast in 3D Printed Molds for Advanced Training in Liver and Breast Imaging Guided Procedures: Training Method Proposal

Radu Claudiu Elisei ¹, C. Tiu², S.C. Moldovan³, F. Graur¹, C. Popa¹, E. Mois¹, N. Al-Hajjar¹, C. Vaida¹

¹Emergency County Hospital, Bistrita, Romania, University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca, General Surgery, Romania, ²Municipal Hospital, Campina, General Surgery, Romania, ³Emergency County Hospital, Bistrita, General Surgery, Romania

Training in any surgical procedure is the shortest path to a faster learning curve and to the best possible mandatory skills. Thus, in mammary gland surgery and in hepatic surgical pathology, ultrasonographically and imagistically guided procedures are performed very frequently: biopsies, drainages, radiofrequency ablations (RFA), etc. The training for performing these procedures can be performed only in a hands-on workshop, using molds of these organs. These workshops usually have significant costs, are not very frequent and have a limited number of participants. There is also not a wide range of phantoms for both liver and breast. Our team came to meet these problems by developing alternatives by creating versatile phantoms and thus offering the possibility to many more doctors to perform such trainings.

For the creation of both the liver and the breast molds, we used the STL files (STereoLithography) obtained by segmenting these organs from images obtained by CT scan. Later we 3D printed the two molds using FMD (fused deposition modeling) technology. We made 2 different concepts of 3D printed molds: 4-quarter mold that is easy to assemble with vessels inside and new mold concept: honey-cone structured breast phantom 3D printed cubic mold.

The next step was to create gelatin and silicone-based breast and liver phantoms, using different recipes depending on the procedure to be designed. Phantoms have been designed for different procedures for both the breast and liver. Thus, gelatin models were designed for the breast for the following procedures: diagnostic ultrasonography with the identification of different structures inside the breast, for ultrasound-guided biopsies, evacuation of collections, installation of ultrasound-guided drains. Gelatin and silicone molds have been designed for the liver for: diagnostic ultrasonography, ultrasound-guided punctures/biopsies, abscess drainage, biliary drainage, RFA, CT and MRI guided procedures. In the case of liver molds, they can have a much greater complexity by mounting inside the main vascular structures of the liver, made of rubber and filled with liquid and even with the possibility of obtaining the doppler effect. These molds have been tested and proven effective in training in diagnostic and interventional ultrasonography of the liver (open, percutaneous, laparoscopic) and breast, as well as in the diagnosis of MRI and CT and guided CT scans.

These liver molds have been tested and proven effective in training in diagnostic and interventional ultrasonography, percutaneous and per operative, open as well as laparoscopic. Gelatin based liver phantom with rubber vessels that accurately replicate important vessels of the liver have proven very useful for training in most percutaneous or laparoscopic imaging-guided procedures that can be performed on the liver.

Breast phantoms made with this mold perfectly mimic the mammary gland and can very accurately reproduce various lesions of it that can be addressed by ultrasound-guided.

AMAZING TECHNOLOGIES

O014—Initial Clinical Experience in Colorectal & General Surgery Using the New HUGO Robotic Assisted Surgery (RAS) System

Venkatesh Munikrishnan ¹, S.K. Swain², A. Baskaran¹, D. Raghavendra², R. Kour¹

¹Apollo Hospitals, Institute of Colorectal Surgery, India, ²Apollo Hospitals, Department of Surgical Gastroenterology, India

Background: The Hugo Robotic Assisted System is a surgical robot introduced recently for human clinical use. This system features an open console (Image 1) with modular robotic arms (Image 2). This paper provides the initial experience of the authors using the HUGO RAS system for General & Colorectal Surgery Procedures

Methods: Patients undergoing Colorectal & General Surgery procedures were included in this prospective clinical trial. Institutional ethical committee approval was obtained and patients were counselled preoperatively with informed consent. Both intraoperative and postoperative clinical data was collected.

Results: A total of 22 patients were included in this initial study. This includes Low Anterior Resection of Rectum (5), Abdominoperineal Resection of Anorectum (n = 1), Hemicolectomy (n = 7), Rectopexy (n = 1), Ventral Hernia Repair (n = 2), Fundoplication (n = 1) and Cholecystectomy (n = 5). The total operative time, port placement time, time to dock the robot, console time, blood loss and length of hospital stay and 30-day morbidity and mortality were recorded. There were no reported robotic system related technical issues during the study period. There were no intra-operative or post-operative complications up to one month follow up.

Conclusion: From our initial experience with the Hugo RAS robotic surgical platform, it appears to be safe for general and major colorectal surgical procedures. This system will be a valuable addition to the existing robotic technology and platforms available for clinical use.

AMAZING TECHNOLOGIES

O015—The Use of a Miniaturised Gamma Probe to Identify Lymph Nodes in Oncological Surgery

Manish Chand ¹, K. Vyas², M.R. Grootendorst²

¹University College London Hospitals, Interventional Sciences and GENIE Centre, Department of Surgery, United Kingdom, ²Lightpoint Medical Ltd., Chesham, United Kingdom

Introduction: Identifying nodal disease intraoperatively is a key determinant to successful oncological surgery. However, these nodes can often be buried within fatty tissue making them difficult to detect using traditional surgical methods. Recently fluorescence has shown some promise in detecting nodal disease but the common fluorophore ICG is non-specific and cannot assess whether a node is malignant, and further, near-infrared cameras only have a depth of penetration of a few millimetres meaning that nodes that are deep in fatty tissue cannot be identified. An alternative approach has been to use radioisotopes but historically gamma probes have been bulky and cumbersome and not suitable for use in minimally-invasive surgery. We present a new technology, SENSEI®, which is a miniaturised gamma probe that can be inserted through a laparoscopic port into the abdominal cavity following establishment of pneumoperitoneum. We have assessed the safety, feasibility and usability of this probe in urological, gynaecological and colorectal cancer being undertaken on the da Vinci robotic platform.

Methods: A series of test cases have been undertaken across different specialties—urology, gynaecology, and colorectal surgery. Patients were administered either 99mTc-nanocolloid alone or in combination with ICG to detect sentinel lymph nodes that were identified on pre-operative SPECT/CT performed the day before or the day of surgery for further localisation.

Results: SENSEI® was able to successfully detect SLNs in all cases and in anatomically challenging areas with limited space and manoeuvrability (e.g. the presacral area). There was a good correlation in nodal detection with and without the use of fluorescence. The technique was safe and no device-related adverse events occurred.

Conclusion: The SENSEI® miniaturised gamma probe shows excellent safety and usability on the da Vinci platform. This has been shown across different specialties. Further investigation will reveal how this technology can be more routinely incorporated into various oncological surgery to improve patient outcomes.

AMAZING TECHNOLOGIES

O016—Quantifying Tissue Perfusion Using Laser Speckle Contrast Imaging and Correlation with Local Tissue Capillary Lactate

C. Nwaiwu¹, Mahdi Al-Taher ², R. Stolyarov³, Y. Liu¹, S. Mehrotra⁴, R. Kimmig⁵, B. Weixler⁶, H. Fuchs⁷, M. Chand⁸, K. Nowak⁹, L. Boni¹⁰, A. Park¹¹, N. Bouvy²

¹Warren Alpert Medical School of Brown University/Rhode Island Hospital, Department of Surgery, USA, ²Maastricht University Medical Center, Department of Surgery, The Netherlands, ³Activ Surgical, Research and Development, USA, ⁴University of Buffalo, Buffalo, Department of Surgery, USA, ⁵University of Duisburg-Essen, Department of Gynecology and Obstetrics, Germany, ⁶Charité University Hospital Berlin, Department of Surgery, Germany, ⁷University of Cologne, Köln, Department of Surgery, Germany, ⁸University College London, Division of Surgery & Interventional Science, United Kingdom, ⁹RoMed Klinikum Rosenheim, Rosenheim, Department of Surgery, Germany, ¹⁰University of Insubria, Varese, Department of Surgery, Minimally Invasive Surgery Research Center, Italy, ¹¹Anne Arundel Medical Center, Department of Surgery, USA

Aim: Quantification of tissue perfusion measurements using LSCI as a real-time dye-less option has been studied but its correlation with widely accepted physiological parameters of tissue ischemia, such as local tissue capillary lactate (LCL) has not been widely reported. LSCI numerical relative perfusion units (RPU) quantifies perfusion in real time using the perfused/ischemic tissue within the field as a reference. We aimed to study the relationship between LSCI RPU and LCL in tissue.

Methods: Two baseline LCL levels were first obtained from a randomly selected loop of small intestine. Ten peripheral mesenteric vessels supplying the middle of the intestinal loop were clipped, creating a graded perfusion model: a middle ischemic segment flanked on either side by two watershed regions and two well perfused segments, respectively (Fig. A-C). One hour after devascularization, a sampling of LCL levels were obtained from each region of interest (ROI) using a lactate analyzer—three from the ischemic segments, and one from each watershed and perfused segment. Then, the LSCI RPU of each ROI was algorithmically obtained using ActivSightTM prototype quantification feature. Background RPU bias was subtracted. ActivSight is a novel LSCI device cleared for use in laparoscopic surgery by the US FDA. It fits between standard laparoscopic camera heads and laparoscopes.

Results: Mean baseline lactate was 8.5 mmol/L. Mean RPU values demonstrated a significant inverse correlation with the corresponding LCL levels for each region of interest (r = –0.86, p = 0.01) (Table). The three ischemic ROI had the lowest mean (± SD) normalized RPU values ranging from 0% (± 1.59) to 9.3% (± 3.28), followed by the watershed regions (51.45% ± 8.31, 59.45% ± 9.18), and the perfused segments (97.2% ± 2.8, 100% ± 2.93), respectively. Conversely, the highest LCL levels were seen in the ischemic segment (25-42.5 mmol/L). The watershed region had lower LCL levels (10.5, 12 mmol/L) while the perfused segments had the lowest (9, 9.5 mmol/L).

Conclusion: LSCI numerical RPU was inversely correlated with LCL levels in ischemic, watershed, and well perfused segments of small intestine. Larger preclinical and clinical trials that benchmark LSCI RPU measurements against LCL and other validated physiological parameters are needed to establish objective cutoff perfusion values for relevant clinical outcomes.

AMAZING TECHNOLOGIES

O017—iSurgeon: Augmented Reality Telestration for Improved Surgical Training

T. Fuchs¹, Eleni Amelia Felinska ¹, E. Felinska¹, A. Kogkas², G. Mylonas², B. Müller-Stich¹, F. Nickel¹

¹Heidelberg University Hospital, Germany, Department of General, Visceral and Transplantation Surgery, Germany, ²Faculty of Medicine, Imperial College London, UK, Department of Surgery and Cancer, United Kingdom

Aims: In laparoscopic surgery trainees need to learn how to interpret the operative field displayed on the laparoscopic screen. Experts currently guide trainees only verbally during laparoscopic surgical procedures. We developed the iSurgeon which allows the instructor to make hand gestures that are detected by a camera and displayed on the laparoscopic screen in augmented reality (AR) to provide visual expert guidance (telestration). Thus, the expert can provide clearer instructions by using gestures in addition to verbal instructions. This study analysed the effect of iSurgeon guided instructions on the gaze behaviour of instructor and trainee during laparoscopic surgery.

Methods: In a randomized-controlled cross-over trial, 40 laparoscopically naive medical students performed 7 basic laparoscopic tasks and one porcine laparoscopic cholecystectomy (task 8) with iSurgeon or with verbal instructions only. We used Pupil Core eye-tracking glasses to capture the instructor’s and the students’ gazes. Gaze behaviour was evaluated for tasks 1-7 by measuring the gaze latency, gaze convergence and collaborative gaze convergence. To measure the performance we counted the errors in tasks 1-7 and evaluated the trainees with structured and standardized performance scores in task 8—the global and task specific objective structuctured assessment of technical skill (OSATS).

Results: There was a significant difference found in tasks 1-7 for gaze latency (p < 0.01), gaze convergence (p < 0.01) and collaborative gaze convergence (p < 0.01). The error number was significantly lower in tasks 1-7 (0.18 ± 0.56 vs. 1.94 ± 1.80, p < 0.01) and the score ratings for task 8 were significantly higher with iSurgeon (global OSATS: 29 ± 2.5 vs. 25 ± 5.5, p < 0.01; task specific OSATS: 60 ± 3 vs. 50 ± 6, p < 0.01).

Conclusions: AR based telestration with the iSurgeon successfully improved laparoscopic surgical performance. Trainee’s gaze behaviour was improved by reducing the time from instruction to fixation on targets and leading to a higher convergence of the instructor’s and the trainee’s gazes during the task. Also, the convergence of trainee’s gaze and target areas increased with the iSurgeon. This suggests that AR based telestration works by means of guiding the trainees’ gazes.

COLORECTAL—Malignant

O019—3D Recons of CT Mesenteric Angiograms for Intraop Patient Safeguarding During Laparoscopic Complete Mesocolic Excision/Central Vascular Ligation Learning Curve

Emma Kearns ¹, R. Cahill¹, E. Kearns¹, M.F. Khan¹, A. Moynihan², A Cahill³

¹University College Dublin, UCD Centre for Precision Surgery, Ireland, ²Mater Misericordiae University Hospital, Surgery, Ireland, ³University College Dublin, UCD Centre for Precision Surgery, Ireland

Introduction: Despite demonstrating superior oncological outcomes, Complete Mesocolic Excision and Central Vascular Ligation (CME/CVL) in colorectal surgery has not been uniformly adopted. There remains some hesitation around the surgical safety of this technique. Postmortem studies have demonstrated significant variations in the relations of the right colon vasculature relative to the superior mesenteric vein, which poses difficulty in surgical performance. Pre-operative 3-D reconstructive imaging may demonstrate these variations in perioperatively before and during surgery especially to help those evolving their surgical practice from traditional hemicolectomy to include CME/CVL.

Methods: Three-dimensional (3-D) reconstructions of CT mesenteric angiograms have been created via an independent commercial service (Visible Patient, Strasbourg, France) for consecutive patients undergoing right hemicolectomy in our institution over the last two years, the time coincident with our learning curve for laparoscopic CME/CVL. The 3D imagery was used to identify the branches of the superior mesenteric artery (SMA) and their relation to the superior mesenteric vein (SMV) by display prior and during complete mesocolic excision and central vascular ligation (CME/CVL) surgery in every case. These reconstructive images were reviewed for accuracy by two researchers independently to classify the presence and relation of the colic arteries to the superior mesenteric vein and intra- and postoperative outcomes documented.

Results: Twenty-five consecutive patients underwent right hemicolectomies with the use of 3-D reconstructive images. The right colic artery (RCA) was present in 20% of cases (n = 5). Where present, the RCA was posterior to the SMV in 60% of cases (n = 3/5). The ileocolic artery (ICA) crossed posterior to the SMV in 76% (n = 19) of cases. The middle colic artery (MCA) was present in 96% of cases (n = 24/25) and anterior to the SMV in 87.5% (n = 21/24) of cases. There were no vascular injuries intraoperative and no anastomotic complications postoperatively.

Conclusion: These 3-D reconstructive images demonstrate similar variations to previous literature with the ICA lying posterior to the SMV and the MCA anterior to the SMV in the majority of cases but allowed both this information and the exact positions of the minority variant anatomy to be personalised to patients at the time of surgery. Access to individualised 3-D reconstructions of patient’s anatomic vascular relations may better inform surgeons and surgical teams both pre-operatively and intra-operatively to safeguard against inadvertent vascular injury.

COLORECTAL—Malignant

O020—Impact of the COVID-19 Pandemic on Stage of Colorectal Cancer at Diagnosis: Single Centre Study Incorporating Urgent Cancer Referral Patterns

Clare Hammer ¹, J. O'Brien¹, C. Rayner¹, T. Rockall¹

¹Royal Surrey Hospital, General Surgery, United Kingdom

Aims: Concerns persist regarding the effect of COVID-19 on colorectal cancer (CRC). NHS data confirms a significant reduction in suspected CRC referral, investigation, and treatment. Following such disruption, later stage disease at diagnosis could be expected. Multi-centre studies during the pandemic confirm worse outcomes for more advanced stage CRC. None have assessed stage at diagnosis for left, right and rectal cancers during the pandemic. Our primary aim was to investigate if there was a difference in stage at diagnosis for the pandemic CRC group compared to two years pre-pandemic. Secondary aim was to determine if there was an association with any change in rate of urgent CRC referrals.

Methods: Retrospective data was extracted from cancer databases for a tertiary CRC centre between January 2018 and January 2022. Cancer codes C18.1 to C21.8 were included and analysed for stage at diagnosis. Wilcoxon signed rank test was used to compare CRC stage between two time periods; a pre-pandemic group prior to March 2020 and a pandemic group after. Linear regression analysis was performed to analyse for change in urgent CRC referrals between these time periods.

Results: Between the pre- and post-pandemic groups (249 vs 221 patients) there was no statistically significant difference in stage of CRC at diagnosis (p = 0.239). Post-hoc analysis showed no difference between tumour site and stage, but there was a non-statistically significant increase in stage T1 and T3 for left and right sided cancer in the pandemic group. Urgent CRC referrals significantly increased after an initial drop (mean 164 vs 192/month) (p = 0.0034). The rate of increase is not significantly different between the pre- and post-pandemic groups.

Conclusion(s): Reassuringly, this study confirms no increase in advanced CRC stage at diagnosis, despite a reduction in urgent referrals at the start of the pandemic. The non-significant increase in left and right T1 and T3 CRC may be confounded by increasing use of the faecal immunochemical test (FIT) and re-configuration of CRC services. CRC referrals have recovered but the rate of increase is not different between the time periods, suggesting there has not been a “bounce” in referral numbers. National studies are required.

COLORECTAL—Malignant

O021—Impact of Imaging Magnification on Colorectal Surgery: Single-center Analysis

Francesco Puccetti ¹, L. Cinelli¹, M. Molteni¹, L. Gozzini¹, L. Barbieri¹, E. Treppiedi¹, A. Cossu¹, U. Elmore¹, U. Casiraghi², R. Rosati¹

¹IRCCS San Raffaele Hospital, Gastrointestinal Surgery, Italy, ²San Raffaele Hospital, Gastrointestinal Surgery, Italy

Introduction: The minimally invasive technique has been increasingly applied in colorectal surgery. Imaging magnification is a relevant component of keyhole surgery, and video systems have been improving over time. This study aims to compare technical and surgical outcomes following the use of 4 K and traditional high-definition (HD) systems in colorectal surgery.

Methods: This study retrospectively analyzed a single-center series of consecutive patients undergoing laparoscopic colorectal surgery, for both malignant and benign diseases, from April 2016 to June 2020. The 4 K imaging system (Olympus VISERA® and SONY Pro® monitor) was introduced in April 2018. All included patients were matched into 4 K and HD groups. A Propensity Score Matching (PSM) was performed according to 15 patients’ perioperative characteristics. Data analysis was stratified with regard to surgical procedures (right/left colectomy and rectum anterior resection). Intraoperative blood loss, operative time, lymph node (LN) harvest, postoperative complications (Clavien-Dindo > 3a), and length of hospital stay (LOS) were considered as primary endpoints. Secondary endpoints included further perioperative outcomes.

Results: Further to the PSM, the study population was matched into 4 K and HD groups of 225 patients each. The two groups presented similar operative time and LN harvest, while intraoperative blood loss appeared significantly lower into the 4 K group (p = 0.008), although it did not require higher volumes of blood transfusion. Postoperative morbidity did not differ between groups in terms of overall complications as well as anastomotic leakages. Major complications were higher in the HD group that also presented a significantly higher rate of abdominal collection (p = 0.045) and reoperation (p = 0.005). Postoperative urinary disorders were also significantly associated with the HD imaging system. After stratification, only the right colectomy subgroup showed similar associations to the whole study population. Imaging systems did not impact LOS, although the HD group showed a significantly higher readmission rate in both the study population (p < 0.001) and subgroups (p < 0.001, p = 0.002, and p = 0.019, respectively).

Discussion: The 4 K imaging system appeared to lead to multiple elements of technical superiority. Improvements were more likely to be measured in right colectomy as well as in those passages of higher degrees of the technical complexity of the other procedures. For this reason, surgeons’ evaluations supported the use of 4 K for all procedures. Readmission rate significance was deemed as a longitudinal bias due to the evolution of perioperative management and discharge criteria.

Conclusions: The 4 K imaging system represents a technological advance and leads to better surgical outcomes, such as the minimization of intraoperative blood loss, major postoperative morbidity, and reoperations.

HEPATO-BILIAIRY & PANCREAS—Pancreas

O022—Oncologic Safety of Minimally Invasive Pancreaticoduodenectomy: A Comparison Between Open and Laparoscopic Approaches

Diogo Melo Pinto ¹, T. Moreira Marques¹, M. Costa², P. Valente¹, R. Peixoto¹, P. Moreira¹, G. Faria¹

¹Unidade Local de Saude de Matosinhos, General Surgery, Portugal, ²Hospital de Penafiel, General Surgery, Portugal

Aims: Minimally invasive (MI) pancreaticoduodenectomy (PD) has faced strong criticism in the scientific community for its complexity and lengthy learning curve. Nevertheless, this approach has been associated to shorter length of stay, fewer complications, and similar oncologic outcomes. We aimed to assess the oncologic safety of the laparoscopic approach by comparing the quality and extent of resection in pathology specimens and survival outcomes.

Methods: A retrospective study was conducted in 64 patients in which a PD was performed between May 2015 and October 2021. Follow-up data was retrieved and analyzed using IBM SPSS Version 28. For all tests, the p-value < 0.05 was considered statistically significant.

Results: Laparoscopic PD was the treatment of choice in 42.2% of the patients, with no statistically significant differences regarding age, sex, malignancy, or tumor localization. The duration of surgery was higher in MIS approach (6 h vs. 9 h; p = 0.005) but the rate of R0 surgery and lymph node harvest were similar (75.8% vs. 90.9%; p = 0.35 and 15 vs. 19; p = 0.24, respectively). There was also no difference regarding recurrence rate (48.5% vs. 36.4%; p = 0.38). At 12 months, overall survival was overlapped (73.4% vs. 77.7%; p = 0.96) and median survival was similar between groups (19 months vs. 16 months; p = 0.96)

Conclusion: Although technically demanding and lengthier, laparoscopic PD is safe and oncological outcomes are not inferior when compared to open approach. Laparoscopic PD is as a reasonable option in patients with pancreatic head and peri-ampullay tumors.

COLORECTAL—Malignant

O023—Clinical Application of Virtual 3D Models in Preoperative Planning for Rectal Cancer Surgery

Anna Przedlacka ¹, P. Tekkis¹, F. Bello², C. Kontovounisios¹

¹Imperial College London, Department of Surgery and Cancer, United Kingdom, ²Imperial College London, Centre for Engagement and Simulation Science, United Kingdom

Aims: 3D modelling technology has been successfully applied in preoperative planning in various surgical fields. In colorectal surgery, CT-based 3D models are utilised to visualise the patient-specific vascular anatomy. The uptake of this technology lags behind in rectal cancer surgery, primarily due to the difficulty involved in creation of the 3D models of rectal cancer through manual segmentation of complex pelvic anatomy based on MRI images. After establishing the feasibility of creation of such models, we explored the utility of their application in preoperative planning for rectal cancer surgery.

Methods: Five patients with diagnosis of rectal cancer, in whom surgical treatment was recommended by the multi-disciplinary team, were selected. Virtual models were created through manual segmentation of staging MRI scans. Open-source software, 3D Slicer, was used. The rectum with the rectal cancer, mesorectum, urinary bladder, ureters, uterus or prostate with seminal vesicles, pelvic bones, vessels and pelvic floor muscles were delineated. Virtual models were used by the operating surgeon during preoperative planning to review the individual anatomy and to plan surgical strategy. Their subjective usefulness was assessed through a questionnaire.

Results: Five virtual 3D models of rectal cancer were created. They could be manipulated in space and each layer could be inspected separately. The models were utilised as an aid in surgeons’ mental preparation for surgery and in decision making with regards to operative strategy. They were applied to assess the morphology of the pelvis, the distance of cancer from the anal sphincter complex and the invasion of the surrounding structures. They aided in decision making regarding the choice of surgical approach, the extent of surgery or the ability to anastomose the colon. They were deemed to be beneficial in the preoperative planning.

Conclusions: The above examples illustrate the usefulness of the virtual 3D models in creation of the surgical roadmap for rectal cancer surgery. They have potential to become an integral part of image-guided, patient-tailored surgery. They can potentially decrease the surgeons’ cognitive load experienced during the mental reconstruction of 2D MRI slices. Future studies are required to assess the objective impact of applying 3D models in preoperative planning on patients’ outcomes.

COLORECTAL—Benign

O024—Impact of Performing Minimally Invasive Surgery on the Prevalence of Musculoskeletal Disorders Among Slovenian General and Abdominal Surgeons: A Cross-sectional Study

Jan Grosek ¹, A. Tomažič¹, Ž. Gorenšek²

¹University Medical Centre Ljubljana, Abdominal Surgery, Slovenia, ²University of Ljubljana, Medical Faculty, Slovenia

Background: Musculoskeletal disorders are one of the most common occupational diseases. Nevertheless, surgeons are known to be at particular risk as they have to face different constraints. A part of those constraints could be determined as risk factors for developing musculoskeletal disorders.

Aim: The aim of our study was i) to define the prevalence of musculoskeletal disease in the population of Slovenian general and abdominal surgeons and ii) to prove that surgeons who have a statistically significant increase in musculoskeletal pain and/or discomfort are those mostly performing minimally invasive surgery.

Methods: In our prospective national cross-sectional study, we included 48 surgeons who were employed in a Slovenian health institution, were regularly performing surgeries and had no history of previous musculoskeletal diseases or injuries in body parts that were marked as painful. We designed a questionnaire based on other standardized questionnaires for our study. Questions were assorted into three different sections—the general part (part I), the surgical part (part II) and the part about work-related musculoskeletal disorders (part III). Results: Statistical analysis included data from 48 surgeons. The prevalence of musculoskeletal disorders among Slovenian general and abdominal surgeons was as much as 91,7%. The most frequently affected parts of the body were lower back (68,8%), neck (45,8%), and upper back (33,3%). Surgeons who were mostly performing minimally invasive surgeries didn't have statistically significant increase in total discomfort score (p = 0,761) or discomfort score of lower back (p = 0,518), neck (p = 0,554), and upper back (p = 0,867). There was a significant interaction between increase in total discomfort score, higher age (p = 0,037), and lower subjective assessment of physical condition (p = 0,007). Lower subjective assessment was also significantly correlated higher discomfort score of neck (p = 0,023) and upper back (p = 0,032). Surgeons performing longer operations had a significant increase in discomfort score of the upper back (p = 0,004) (calculated with multiple linear regression).

Conclusions: Our findings revealed a high prevalence (higher than 75%) of musculoskeletal diseases among Slovenian general and abdominal surgeons. The minimally invasive approach did not significantly affect the prevalence of musculoskeletal disorders. There was a significant correlation between the prevalence of musculoskeletal disorders age, subjective assessment of physical condition, and performance of longer procedures.

BARIATRICS—Laparoscopic

O025—Robot-Assisted Revisional Bariatric Surgery. A Review of Cases from a European Center of Excellence

R. Vilallonga¹, A. Cirera de Tudela ¹, M. Huerta ¹, A. Garcia Ruiz de Gordejuela¹, E. Caubet¹, O. Gonzalez², M. Moratal¹, M. Comas², A. Ciudin², M. Armengol¹

¹Vall d'Hebron University Hospital, Endocrine, Bariatric and Metabolic Surgery Unit. Department of General and Digestive Surgery, Spain, ²Vall d’Hebron University Hospital, Department of Endocrinology and Nutrition. Vall d’Hebron University Hospital. Universitat Autònoma de Barcelona, Spain

Objectives: The use of robotic technology in the field of revision bariatric surgery has increased significantly in recent years. However, there are still many doubts about its usefulness in terms of postoperative complications, costs and technical aspects, thus posing a technical challenge associated with more postoperative complications compared to primary bariatric surgery. The objective of this work is to describe our experience in a high-volume center through a review of cases undergoing robot-assisted revisional bariatric surgery.

Material and Methods: A retrospective review of our experience was carried out to assess the impact of robotic revision surgery in the field of bariatric surgery, analyzing the type of surgery, results, and associated postoperative complications.

Results: A total of 21 patients (12 men and 9 women) were operated on. The most frequently performed surgeries were conversion from vertical gastrectomy to Roux-en-Y gastric bypass (n = 13) and conversion from sleeve to a Single Anastomosis Duodeno-Ileal bypass or SADI-S in second stage (n = 6). The remaining two cases consisted of reoperations for Roux-en-Y bypass due to gastro-gastric fistula. The mean length of hospital stay was 2.6 days. Regarding the rate of complications, there was only one case of reoperation for anastomotic leak in a patient who underwent a second-stage SADI-S.

Conclusions: In our experience, revisional robotic bariatric surgery shows better results compared to the standard laparoscopic technique in terms of efficacy, safety and hospital stay. Our results suggest that, once a learning curve is established, robot-assisted revision bariatric surgery can be performed, which is part of the democratization and standardization process of obesity surgery.

BARIATRICS—Laparoscopic

O026—A Retrospective Analysis of More Than 500 Robotic-Assisted Bariatric Surgery Cases. Experience from a High Volume European Hospital

Arturo Cirera de Tudela ¹, R. Vilallonga², A. Garcia Ruiz de Gordejuela², E. Caubet², O. Gonzalez², D. Herms¹, M. Moratal¹, M. Huerta¹, M. Comas³, A. Ciudin³, M. Armengol¹

¹Vall d'Hebron University Hospital, Department of General and Digestive Surgery, Universitat Autònoma de Barcelona, Spain, ²Vall d’Hebron University Hospital, Endocrine, Bariatric and Metabolic Surgery Unit. Department of General and Digestive Surgery, Spain, ³Vall d’Hebron University Hospital, Department of Endocrinology and Nutrition, Universitat Autònoma de Barcelona, Spain

Objectives: Robotic-assisted surgery is, nowadays, an increasingly evident reality in the field of Gastrointestinal Surgery, especially in Bariatric Surgery. The main objective of this communication is to present a retrospective review of robotic bariatric surgery cases in a high-volume European Center of Excellence in the last 11 years.

Material and Methods: A retrospective observational study was carried out of all patients who underwent robot-assisted bariatric surgery included between April 2010 and November 2021. In this period, a total of 535 patients underwent vertical gastrectomy techniques (n = 123), Roux-en-Y gastric bypass (n = 403) and duodenal ileal bypass with single anastomosis or SADI-S (n = 9) by six different surgeons from our center, all of them experts in the standard laparoscopic technique. The robots used were the Da Vinci S® and later the DaVinci Xi® (Intuitive SurgicalTM).

Results: A total of 535 patients were included (377 women and 158 men), with a mean age of 46 years, a mean body mass index (BMI) of 44.56 kg/m², and a mean follow-up time of 41 months. The total percentage of comorbidity was 6.01%, with no case of death. Table 1 shows the results in terms of demographic data before surgery, reduction in body weight, improvement in preoperative comorbidities, and postoperative complications.

Conclusions: To minimize the rate of post-surgical complications and to achieve optimal clinical results, any new surgical technique requires a learning curve with a minimum of cases per surgeon. In our experience, the use of the robot is part of avant-garde and fundamental technological strategy in the democratization process of bariatric surgery. The results obtained in our center with the robotic modality in terms of weight loss, resolution of comorbidities, and the number of intra- and ostoperative complications are encouraging.

BARIATRICS—Laparoscopic

O027—Risk Factors for Early Postoperative Complications After Revisional Roux-en-Y Gastric Bypass—Results from Multicenter Polish Revision Obesity Surgery Study (PROSS)

Izabela Karpińska ¹, J. Rymarowicz¹, P. Zarzycki¹, M. Matyja¹, P. Małczak¹, J. Kulawik¹, M. Pędziwiatr¹, P. Major¹

¹Jagiellonian University Medical College, 2nd Department of General Surgery, Poland

Aims: There is growing number of patients requiring revisional bariatric surgery worldwide. Currently Roux-en-Y gastric bypass (RYGB) is the most common revisional bariatric procedure performed. Although bariatric surgery is considered to be safe, revisional operations are associated with increased morbidity compared with primary interventions. Better understanding of postoperative complications may help to optimize surgical outcomes. We aimed to determine the predictive factors of early complications after revisional RYGB.

Methods: The study comprised patients undergoing revisional RYGB from January 2007 to February 2021 in 17 polish bariatric centers—Polish Revision Obesity Surgery Study (PROSS). The retrospective analysis included demographical and clinical characteristics, presence of comorbidities as well as surgical technique. The assessed endpoint was early complications defined as any deviation from normal postoperative course occurred within 30 days after surgery. To identify predictors of postoperative morbidity we evaluated the relationship between preoperative indicators and outcomes by uni- and multivariate logistic regression.

Results: Out of 287 patients, 232 (80,8%) were women. Mean preoperative BMI was 38,5 kg/m2. Three most common comorbidities were: hypertension (39,7%), diabetes mellitus (18,1%) and gastrointestinal reflux (GERD, 16,4%). The majority of patients were reoperated due to obesity recurrence (58,2%). Sleeve gastrectomy (SG) was the most frequently performed primary procedure (53,0%). General morbidity reached 33,4%. Three most common complications were: reflux esophagitis (23,9%), persistent vomiting (6,6%) and bowel obstruction/anastomotic stricture (5,2%).

According to univariate logistic regression preoperative weight and BMI, sex, GERD, autoimmune or psychiatric diseases, obesity recurrence or complications as indications for reoperation and primary adjustable gastric band (AGB) or SG showed significant correlation with 30-day complications after revisional RYGB.

Multivariate logistic regression model confirmed GERD (OR = 11,2), psychiatric disease (OR = 5,1), complications as indication for reoperation (OR = 15,3) and primary AGB (OR = 7,4) to have significant impact on postoperative morbidity.

Conclusions: Even in experienced hands, revisional RYGB surgery is associated with greater morbidity and should be approached with significant caution. GERD, psychiatric disease, complications as indication for reoperation and primary AGB are independent predictive factors of 30-day complications after revisional RYGB. Recognition and optimization of identified risk factors would be valuable in preoperative patients assessment.

BARIATRICS—Physiology

O028—Current Status of Metabolic/Bariatric Surgery in Type 1 Diabetes Mellitus: an Updated Systematic Review and Meta-analysis

Panagiotis Lainas ¹, R. Valizadeh², A. Davarpanah Jazi³, S. Shahabi Shahmiri⁴, J.A. Lopez Martinez⁵, A. Mousavimaleki⁶, F. Eghbali⁷, A. Aliakbar⁸, H. Atarodi⁹, E. Aghajani¹⁰, M. Kermansaravi¹¹

¹Metropolitan Hospital, HEAL Academy, Department of Digestive Surgery, Greece, ²Iran University of Medical Sciences, Tehran, Minimally Invasive Surgery Research Center, Iran, ³Shariati Hospital, Isfahan, Department of General Surgery, Iran, ⁴Iran University of Medical Sciences, Tehran, Minimally Invasive Surgery Research Center, Iran, ⁵Dalinde Medical Center and Angles Group, Mexico City, Mexico, ⁶Iran University of Medical Sciences, Tehran, Minimally Invasive Surgery Research Center, Iran, ⁷Minimally Invasive Surgery Research Center, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Department of Minimally Invasive and Bariatric Surgery, Iran, ⁸Iran University of Medical Sciences, Tehran, Minimally Invasive Surgery Research Center, Iran, ⁹Iran University of Medical Sciences, Tehran, Minimally Invasive Surgery Research Center, Iran, ¹⁰Aleris Hospital, Oslo, Department of Surgery, Norway, ¹¹Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Department of Minimally Invasive and Bariatric Surgery, Iran

Aims: This systematic review and meta-analysis intend to evaluate the efficacy of metabolic/bariatric surgeries (MBS) in patients with type-1 diabetes mellitus (T1DM).

Methods: A systematic literature search and meta-analysis was performed in electronic databases including Pubmed, EMBASE, SCOPUS up to July 2021. Title searching was restricted to include “type 1 diabetes mellitus” in conjunction with the following keywords/terms: bariatric, gastric bypass, gastric band, and sleeve gastrectomy. After screening abstracts against the selection criteria, 27 full-text articles were selected and evaluated for eligibility.

Results: In total, 27 primary studies comprising 648 subjects were included in this systematic review and meta-analysis. Patients had a mean age of 38.0 ± 7.3 years. Preoperative mean BMI was 42.6 ± 4.7 kg/m2 and 29.4 ± 4.7 kg/m2 after surgery, respectively. Follow-up time had a mean of 32.6 ± 23.2 months (n = 26). The most favorable common procedure for MBS was Roux-en-Y gastric bypass (RYGB) accounting for 72.5% of procedures (n = 470). Following bariatric surgeries in patients with type 1 diabetes mellitus, insulin (unit/d) decreased by a weighted mean difference (WMD) of -10.59. Also, insulin (unit/kg/d) decreased by a WMD of -0.21 and HbA1C decreased by a WMD of -0.71, showing the acceptable and durable effects of bariatric surgical procedures.

Conclusions: The current study shows that MBS reduces postoperative insulin requirement and improves HbA1c in obese and severely obese T1DM patients. A careful multidisciplinary approach is necessary in each of these patients to determine whether weight reduction and benefits of obesity comorbidities outweigh the overall operation risks. High-volume randomized, prospective trials are necessary to elucidate the role of MBS in the treatment of severely obese patients with T1DM.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

O031—Evaluation of the Novel Electrosurgical Dissector and Vessel Sealer EleXor Including a Likert Scale Survey of Operators

Christian Thiel ¹, L.T. Frericks², A. Königrainer¹, M. Schenk¹, S. Brucker¹, B. Kraemer¹, V. Steger¹, U. Biber², W. Linzenbold², M. Enderle², K. Thiel¹

¹Tuebingen University Hospital, Department of General, Visceral and Transplant Surgery, Germany, ²Erbe Elektromedizin, Research and Basic Technologies/Clinical Studies and Medical Affairs, Germany

Aims: Bipolar vessel sealers have become indispensable for both minimally invasive and open surgical procedures in many medical disciplines and high demands have to be fulfilled. Aim of our study was to evaluate the performance of the novel EleXor (ELX), which simultaneously seals and cuts tissue using an electrical blade for cutting (e-blade).

Methods: In an ex vivo setting sealing rate, burst pressure and thermal spread were analysed. In a second step, ELX was assessed in a prospective, randomized, controlled in vivo study in two female German Landrace pigs (59 kg and 62 kg): sealing rate, sealing time and acute complications were documented. Handling and usability were evaluated using Likert scale surveys (1 = very poor; 5 = very good) answered by two gynaecologists, one thoracic surgeon and one visceral surgeon. This part of the study included a comparison with ENSEAL G2 (ENS).

Results: Ex vivo, the sealing rate of ELX was 91.7% (33/36) for renal arteries with a mean diameter of 4.4 ± 0.5 mm and a mean burst pressure of 1040 ± 350 mmHg (n = 72 vessel parts). The maximum jaw temperature was 87 ± 4 °C and the lateral thermal spread was 0.8 ± 0.2 mm (n = 36). In vivo, the sealing rate was similar for veins (96.3%, 26/27) and arteries (88.9%, 24/27; p = 0.61). The bleeding rate for dissection and vessel sealing irrespective of tissue type was 1.2% (9/774 instrument activations). The median seal and cut time was 1.6 s (range 1.3 s—2.9 s, n = 49 vessels between 2-6 mm). In 13 surgical subtasks, the mean rating of ELX in the surveys was 4.4 ± 0.6 Likert points (LP). In five shared surgical subtasks, ELX was rated better than ENS (4.4 ± 0.5 LP vs. 3.4 ± 0.6 LP; p = 0.016).

Conclusion: ELX seals and cuts reliable and rapidly vessels up to 6 mm in diameter. The performance of ELX was rated good to very good and better than ENS for the procedures considered.

ROBOTICS & NEW TECHNIQUES—Education

O032—Learning Curve of Surgical Novices Using the New ArtiSential Laparoscopic Device

Rabi Raj Datta ¹, L. Mader¹, T. Dratsch¹, J. Toader¹, R. Wahba¹, B. Babic¹, D. Müller¹, C. Bruns¹, H. Fuchs¹

¹University Hospital Cologne, Visceral Surgery, Germany

Objective: Laparoscopy has undergone an impressive development in recent years, with robotic assisted surgery as one of the latest steps. Newly presented simple alternatives can mimic certain robotic features. The recently CE-cleared ArtiSential single-use device promises to combine robotic dexterity with conventional laparoscopic instruments. The aim of this preliminary dry lab study is to report how novices without any laparoscopic experience perform laparoscopic tasks (rope pass, peg transfer, needle thread, recapping, and knot tying) with the new ArtiSential instruments and to examine the learning curves in comparison to conventional laparoscopic technology. Description of the technology and method of its use: A set of 5 laparoscopic skill tests (rope pass, peg transfer, needle thread, recapping, and knot tying) were performed with 3 repetitions according to our academic institutional standard as published previously. Eight Medical students (7 female, 1 male) performed all tests with both standard laparoscopic instruments and the new device (see Fig. 1). Time was recorded. To test whether laparoscopic performance improved over the three trials and whether the type of laparoscopic system influenced performance on the task, we conducted a 3 × 2 mixed ANOVA.

Preliminary Results: There was a significant main effect for trial, F(2, 14) = 5.19, p = .021, η_p² = .426, indicating that the laparoscopic performance improved from the first to the third trial for both laparoscopic systems (see Fig. 2). There was also a significant main effect for laparoscopic system, F(1, 7) = 7.85, p = .026, η_p² = .529, indicating that the students took on average longer to complete the rope pass task using the ArtiSential. There were no significant effects for the tasks rope pass, peg transfer, needle thread, recapping, and knot tying.

Conclusion: This preliminary study analyzing learning curves of the new Artisential Device shows steep learning curves for both the classic laparoscopic system as well as Artisential, indicating that novices improved quickly using both systems. Fundamental training maintains to be crucial for complex laparoscopic tasks especially when using new devices.

ROBOTICS & NEW TECHNIQUES—COLORECTAL

O033—Automatic Optical Biopsy for Colorectal Cancer Using Hyperspectral Imaging and Artificial Neural Networks

Manuel Barberio ¹, T. Collins², V. Bencteux², S. Benedicenti³, M. Moretti³, M. Mita³, B. Barbieri³, A. Altamura³, F. Rubichi³, G. Giaracuni³, J. Marescaux², A. Hostettler², M. Diana², M. Viola³

¹University Hospital of Zurich, Department of Surgery, Switzerland, ²University Hospital of Zurich, Department of Radiology, Switzerland, ¹ORSI Academy, Urology, Belgium, ²Surgical Artificial Intelligence and Innovation Laboratory, Surgery, USA, ³Universitätsklinikum Köln, Surgery, Germany, ¹Card. G. Panico Hospital/IRCAD France, Surgery, France, ²IRCAD France, Research, France, ³Card. G. Panico, Surgery, Italy

Aims: Intraoperative identification of cancerous tissue is fundamental during oncological endoscopic or surgical procedures. Tumor recognition is currently realized through frozen sections, implying invasive sampling, operative time loss and reduced precision compared to traditional histopathological examination. Hyperspectral imaging (HSI), a contrast-free and contactless imaging technology, providing a spatially resolved spectroscopic analysis, generates information-rich datasets, with the potential to differentiate tissue at a cellular level. However, complex data extraction algorithms are required to obtain discriminative information. Recently, artificial intelligence (AI) algorithms have been successfully trained to automatically discriminate biological tissue types using HSI data. However, to achieve a clinically sound recognition accuracy, large numbers of training samples are necessary. We hypothesize that using advanced AI algorithms: convolutional neural networks (CNN), highly accurate automatic cancer recognition can be achieved even with small number of patients.

Methods: In 34 patients undergoing colorectal resections for cancer, immediately after extraction, the specimen was opened, the tumor-baring section was exposed and imaged using HSI. Cancer and normal mucosa were manually annotated in each image, based on final histopathological results. State of the art CNN algorithms were trained for automatic cancer recognition, and their accuracy was tested with k-fold- cross-validation (fivefold).

Results: In 34 colorectal adenocarcinomas (19 left, 11 right, 4 transverse colon and 2 rectum), 7 had a local initial stage (T1-2) and 27 had a local advanced stage (T3-4). The overall automatic recognition showed high sensitivity and specificity (86% and 90%, respectively) for cancer recognition. When considering the locally advanced stage group, the sensitivity and specificity were 85% and 94% respectively. For the locally initial stage group, the sensitivity and specificity were 89% and 76% respectively.

Conclusion(s): Automatic colorectal cancer recognition on fresh specimens using HSI and properly trained advanced AI’s algorithms seems feasible and highly accurate even with small datasets, regardless of the local tumor extension. In the near future, this approach might become a useful intraoperative tool during oncological endoscopic and surgical procedures, resulting in precise and non-destructive optical biopsies, in order to ensure tumor-free resection margins.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

O034—Prediction of Laparoscopic Skill: Objective Learning Curve Analysis

Masie Rahimi ¹, S.F. Hardon², E. Uluç², H.J. Bonjer¹, F. Daams²

¹Amsterdam UMC/ Amsterdam Skills Centre, Surgery, The Netherlands, ²Amsterdam UMC, Surgery, The Netherlands

Introduction: Laparoscopic training is proved to enhance patient safety and objective assessment of laparoscopic technical skill has been validated for surgical trainees. However, since capacity and funds for training are limited, warranting a tailored approach, it is important to detect under and overperformers in an early stage. This study aimed to predict the learning curve within a 3-week laparoscopic training program based on objective learning curve analysis.

Methods: In a laparoscopic training program first-year surgical residents, prospective data-analysis was performed using objectively measured data of six different tasks. Force, motion and time, three objective measures of tissue manipulation and instrument handling, were included. Linear regression tests were used to predict the learning curve and the amount of repetitions required to reach proficiency.

Results: A total of 6,010 trials, performed by 42 trainees from 13 Dutch hospitals were assessed and included for analysis. Proficiency level was determined as a mean result of 7 experts performing 42 trials. Learning curve graphs and prediction models for each task was calculated. Within 17 of 18 parameters, the baseline performance had a statistically significant relationship with the number of sessions needed to reach the proficiency level.

Conclusion: This study showed that prediction of expected work load to reach proficiency levels using objective force, motion and time parameters is possible. These findings enable tailored laparoscopy training based on early learning curve analysis.

ROBOTICS & NEW TECHNIQUES—Basic and Technical Research

O035—Does Speed Equal Quality? Time Pressure Impairs Surgical Skills During Minimally Invasive Surgery During a Prospective Crossover Trial

Alfred Schneider ¹, F. von Bechtolsheim¹, S. Schmidt¹, S. Abel², M. Wekenborg³, S. Bodenstedt³, S. Speidel⁴, F. Oehme⁴, J. Weitz⁴, M. Distler⁴

¹University Hospital Carl Gustav Carus, Technical University Dresden, Department for Visceral, Thoracic and Vascular Surgery, Germany, ²Technical University Dresden, Chair of Biopsychology, Germany, ³Technical University Dresden, Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT) Dresden, Germany, ⁴Technical University Dresden, Department for Visceral, Thoracic and Vascular Surgery, Germany

Objective: The primary objective of this trial was to investigate the effect of time pressure on surgical quality, as assessed by force application and the incidence of surgical errors during minimally invasive surgical tasks.

Summary Background Data: Time pressure can cause stress, subsequently influencing surgical operation. It remains unknown to what extent stress can affect the performance of surgeons.

Methods: Sixty-three participants (43 surgical novices trained to proficiency and 20 surgeons) performed four laparoscopic tasks (PEG transfer, precise Cutting, gallbladder resection, surgical knot) both with and without time pressure. The primary endpoint was the occurrence of significant errors and the mean and maximal force exertion during each task.

Results: Time pressure led to a significant shortening of the task time in all four tasks, regardless of the participant’s experience level. However, significantly more errors were noticed under time pressure (suture precision P < 0,001). Moreover, time pressure led to a significant increase in mean force in all tasks as shown in Fig. 1 (PEG: P < 0,001; precision cutting: P = 0,001; surgical knot: P < 0,001; gallbladder: P = 0,004). In three out of four tasks the maximal force application (PEG: P < 0,001; precision cutting: P < 0,001, surgical knot: P = 0,006) increased significantly as we can see in Fig. 2. Cohort analysis revealed that surgical novices and surgeons were significantly impaired by time pressure regarding the incidence of errors and force application. Still, novices performed worse regarding mean and maximal force exertion under time pressure.

Conclusions: Time pressure during minimally invasive surgery may improve procedural time but impair the quality of surgical performance in terms of the incidence of errors and force exertion. Experience may only partially compensate for the negative influence of time pressure.

ROBOTICS & NEW TECHNIQUES—Colorectal

O036—Right Colectomy with Intracorporeal Anastomosis: A European Multicenter Propensity Score Analysis of Robotic vs. Laparoscopic Procedures

Nicola de'Angelis ¹, G Casoni Pattacini², D.C Winter³, R. Micelli Lupinacci⁴, M. Milone⁵, V. Celentano⁶, G. Bianchi⁷, V. Tonini⁸, A. Valverde⁹, L. Zorcolo¹⁰, F. Ris¹¹, M. Piccoli¹², E. Espin Basany¹³

¹Henri Mondor Hospital and University Paris Est—UPEC, Digestive and HPB Surgery, France, ²Ospedale Civile Baggiovara, Unit of General, Emergency Surgery and New Technologies, Italy, ³St. Vincent's University Hospital, Department of Surgery, Ireland, ⁴Ambroise Paré Hospital, Department of Digestive, Oncologic and Metabolic Surgery, France, ⁵"Federico II" University of Naples, Department of Clinical Medicine and Surgery, Italy, ⁶Imperial College, Department of Surgery and Cancer, United Kingdom, ⁷Henri Mondor Hospital, Digestive and HPB Surgery, France, ⁸IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Emergency Surgery Department, Italy, ⁹Groupe hospitalier Diaconesses Croix Saint-Simon, France, ¹⁰University of Cagliari, Colon and Rectal Surgery Unit, Italy, ¹¹Faculty of Medicine, Geneva University Hospitals, Division of Abdominal and Transplantation Surgery, Department of Surgery, Switzerland, ¹²OCB (Ospedale Civile Baggiovara), Unit of General, Emergency Surgery and New Technologies, Italy, ¹³University Hospital Vall d'Hebron-Universitat Autonoma de Barcelona, Unit ofColorectal Surgery, Department of General and Digestive Surgery, Spain

Aim: Minimally invasive surgery is widely applied for right colon cancer resection. The present study aimed to compare the short- and long-term outcomes of robotic (RRC-IA) vs. laparoscopic (LRC-IA) right colectomy with intracorporeal anastomosis using a propensity score matching analysis based on a large European multicentric cohort of patients with nonmetastatic right colon cancer.

Methods: On the Minimally invasivE surgery for oncologic Right ColectomY (MERCY) Study Group database, elective curative-intent RRC-IA and LRC-IA performed between January 2014 and December 2020 were selected. The two groups were matched by propensity score (PSM) and compared with respect to operative and postoperative outcomes, including 5-year survival rates.

Results: Initially, 596 patients were selected, including 194 RRC-IA and 402 LRC-IA patients. After PSM, 292 patients (146 per group) were compared. There was no significant difference between RRC-IA and LRC-IA in terms of operative time, intraoperative complication rate, conversion to open surgery, postoperative morbidity (34% in each group), or 5-yr survival (80.5% for RRC-IA and 74.7% for LRC-IA; p = 0.942). R0 resection was obtained in 99.6% of the patients, and more than 12 lymph nodes were harvested in 92.1% of patients, without group-related differences. RRC-IA procedures were associated with a significantly more frequent use of indocyanine green fluorescence than LRC-IA (37% vs. 15.8%; p < 0.0001).

Conclusion: The present study provides evidence that RRC-IA and LRC-IA performed for the resection of right colon cancer are associated with comparable short- and long-term outcomes, which do not appear to be influenced by the type of surgical approach.

ROBOTICS & NEW TECHNIQUES—Technology

O040—Surgomics: Towards Artificial Intelligence for Personalized Prediction of Undesired Events in Surgical Oncology Using Multimodal Intraoperative Data

Martin Wagner ¹, J.M. Brandenburg¹, S. Bodenstedt², A.C. Jenke², A. Stern³, A. Schulze¹, F.R. Kolbinger⁴, M.T.J. Daum¹, N. Bhasker², M. Dugas¹, O. Heinze¹, O. Klar¹, L. Mündermann³, J. Fallert³, M. Distler⁴, J. Weitz⁴, B.P. Müller-Stich¹, S.Speidel²

¹Heidelberg University Hospital, General, Visceral and Transplantation Surgery, Germany, ²National Center for Tumor Diseases Dresden, Translational Surgical Oncology, Germany, ³Karl Storz SE & Co KG Tuttlingen, Corporate Research and Technology, Germany, ⁴University Hospital and Faculty of Medicine Carl Gustav Carus Dresden, Department of Visceral, Thoracic and Vascular Surgery, Germany

Introduction: Minimally invasive oncologic surgery has to be radical, but may lead to undesired events that can cause harm for the patient. In analogy to radiomics and genomics we aim for surgomics to predict undesired events. We define surgomics as the entirety of intraoperative process characteristics, surgomic features, which represent personalized information about surgical patients. These surgomic features need to be extracted from data sources like endoscopic videos, intraoperative imaging methods, vital sign monitoring or medical devices by means of machine learning and artificial intelligence. Taken together with pre- and postoperative information such as comorbidities, radiomic features or postoperative lab values, Surgomics may help to predict morbidity, mortality and survival.

Methods: To assess the different data available in the intraoperative setting and their potential relevance for patient outcome, we discussed them in a multidisciplinary team with experts from the fields of surgery and computer science. Based on this discussion, several surgomic features have been identified, categorized and rated for surgical importance for outcome prediction as well as technical feasibility of automatic feature extraction from surgical data. For an initial evaluation, ten video-based surgomic features were selected (level of smoke and blood, presence of six instruments and two anatomical structures) in a video of robot-assisted esophagectomy. With the annotated dataset a DenseNet121 was trained.

Results: The multidisciplinary team identified over 60 surgomic features. Besides the ten features evaluated in this study, more examples include the texture of lung or liver, GOALS score and the RGB-colour of anastomosis in the video or arterial blood pressure. Rating regarding feasibility for automatic recognition was highest for instrument use with 8.1 out of 10 and regarding relevance for morbidity and mortality highest for surgical skill and quality of performance with 8.6 out of 10. For the ten developed features, preliminary recognition results were achieved with an overall F1-score of 0,652 (SD 0,305).

Conclusion: Machine learning may extract information hidden in surgical datasets. Despite promising first results, it is yet unknown how robust the feature detection is and whether the extracted features can improve surgical outcome prediction. With surgomics we aim to apply these methods to the personalized therapy of surgical oncological patients. In a next step we will continue to rate the identified surgomic features in a questionnaire with international experts from surgery and computer science to establish a roadmap for further development.

HERNIA-ADHESIONS—Adhesions

O041—Risk factors for Readmission Related to Adhesions and Reoperation After Gynaecological Surgery: A Nationwide Cohort Study

Masja Toneman ¹, T. Groenveld¹, P. Krielen¹, A. Hooker², A. Di Spiezio Sardo³, P Koninckx⁴, R. De Wilde⁵, A. Nap⁶, H. van Goor¹, P. Pargmae⁶, R. ten Broek¹

¹Radboudumc, Surgery, The Netherlands, ²Zaans Medisch Centrum (ZMC), Gynaecology, The Netherlands, ³School of Medicine, University of Naples Federico II, Naples, Department of Public Health, Italy, ⁴KU Leuven, Gynaecology, Belgium, ⁵University Hospital for Gynecology, Carl von Ossietzky, University, Oldenburg, Gynaecology, Germany, ⁶Radboudumc, Gynaecology, The Netherlands

Aim: Women in developed countries have more than 50% risk of undergoing abdominal or pelvic surgery during their lives, putting them at high risk for adhesion-related complications. Gynecological procedures are often the first abdominal surgery performed in women. Adhesion-related complications include small bowel obstruction, chronic (pelvic) pain, subfertility and higher risk for complications during reoperation. The aim of this study is to predict the risk for readmission related to adhesions and reoperation after gynaecologic surgery.

Methods: A nationwide retrospective cohort study was conducted including all women undergoing a gynecological procedure as the initial abdominal or pelvic operation in Scotland between June 1st 2009 and June 30th 2011. Prediction models were fitted using cox-regression estimating the 2- and 5-year risk of readmission (directly or possibly related to adhesions) and abdominal reoperation. Nomograms of these models were constructed. To evaluate the reliability of the created prediction model, an internal cross‐validation was performed using bootstrap methods.

Results: From the total of 18452 women 2719 (14.7%) were readmitted possibly or directly related to adhesions, reoperations were performed in 2679 (14.5%). Risk factors for readmission directly or possibly related to adhesions were surgical approach, higher age, malignancy as indication, operation site, intraabdominal infection, radiotherapy in history, application of mesh and inflammatory bowel disease as comorbidity. Risk of readmission was lower following fertility surgery. The prediction model for readmissions had a good predictive reliability (c-statistics 0.71). The prediction model for reoperation comprised the same risk factors with the addition of adhesiolysis during initial surgery. The prediction model for the risk of reoperation had a moderate predictive reliability (c-statistics 0.65).

Conclusion: Risk factors for adhesion related consequences were identified and prediction models were constructed. The nomograms can guide the targeted use of adhesion prevention methods and the preoperative patient information.

HERNIA-ADHESIONS—Emergency Surgery

O042—Laparoscopic Treatment of Small Bowel Occlusion. The Utility of Intraoperative ICG-Fluorescence Angiography to Assess Bowel Viability: Case Series

Diego Coletta ¹, F. Guerra², P.A. Greco¹, F. Petrelli¹, E. Eugeni¹, A. Patriti¹

¹Azienda Ospedaliera Ospedali Riuniti Marche Nord, Chirurgia Generale, Italy, ²USL Toscana SudEst, Ospedale della Misericordia, Chirurgia Generale, Italy

Aim: Although the evidence supports the feasibility of a laparoscopic approach for acute small bowel obstruction, the difficulty to adequately evaluate the compromised bowel segments has been cited as a principal limitation. The aim of this work is to report a novel application of extemporaneous indocyanine green (ICG) fluorescence to assess bowel viability where there is a concern for ischaemic damage.

Method: After the cause of obstruction has been identified and resolved, and where there are dubious signs of bowel insufficient vascular supply, fluorescent selective angiography is undertaken. The segment of the bowel in question is observed under both normal and fluorescent light to assess local microcirculation. The adequacy of both the arterial supply and the venous drainage is appraised to define bowel viability.

Results: From January 2018 to January 2022, out of 124 patients who have undergone surgery for acute small bowel obstruction with a minimally invasive approach, twelve underwent extemporaneous ICG fluorescence angiography to assess bowel viability. We described the different presentations with their relevant management.

Conclusions: Selective use of intraoperative fluorescent angiography may overcome some of the intrinsic limitations of laparoscopy in assessing bowel viability during surgery for acute small bowel obstruction.

HERNIA-ADHESIONS—Adhesions

O043—Efficacy of Elective Adhesiolysis in Prevention of Adhesive Small Bowel Obstruction in Patients with Symptomatic Adhesions

Main author: Bastiaan van den Beukel: Bastiaan van den Beukel ¹, M. Toneman¹, F. van Veelen¹, N. de Bouvy², H. van Goor, R.P.G. ten Broek¹

¹RadboudUMC, Surgery, The Netherlands, ²Maastricht Universitair Medisch Centrum, Surgery, The Netherlands

Aim: Adhesive small bowel obstruction (ASBO) is one of the most important complication of adhesion, and a frequent cause of readmissions and emergency abdominal surgery. Morbidity from ASBO is high and 30-day mortality is estimated at 5-7%. With every recurrence of ASBO the risk of new episodes increases. Elective adhesiolysis with adhesion barriers has effectively been applied in selected cases of patients with adhesion-related pain. It is unknown of elective adhesiolysis can also reduce the risk of (recurring) ADBO, In this study we evaluate the effect of elective adhesiolysis with use of an anti-adhesion barrier on the risk of (recurrent) ASBO.

Methods: This is a retrospective cohort study including patients referred to our expert center for adhesion related symptoms, such as chronic pain or recurring ASBO. Diagnosis of abdominal adhesions was confirmed by CineMRI. Electronic patient files comprising hospital and general practitioner data were used to identify and verify readmissions for ASBO. Primary outcome is time till episode of ASBO compared between patients who had elective adhesiolysis with the use of a barrier versus patients who had no elective surgical treatment for adhesions. Incidence of ASBO is compared using Log-rank test.

Results: A total of 127 patients were recruited. Sixty-six patients underwent adhesiolysis of whom 27 patients had a history of ASBO. Out of 61 patient who had no surgical treatment, 30 had ASBO in history. The number of patients and number of episodes of ASBO in history were equally divided between the groups. Kaplan- Meier estimate for the risk of readmission of ASBO was 6.8% after 5 years following elective adhesiolysis vs. 19.8% in the non-operative group (Fig. 1). The difference in time to reoperation between groups was significant after correction for history of ASBO (p = 0.021). In the subgroup of patients with previous episodes of ASBO in history, the 5-year Kaplan- Meier estimated for recurrent ASBO was 16.7% following elective adhesiolysis compared to 37.8% in non-surgical group (Fig. 2). The difference was significant p = 0.040.

Conclusion: Elective adhesiolysis with application of an anti-adhesion barrier is useful in prevention of recurrent ASBO in patients with symptomatic adhesions.

HERNIA-ADHESIONS—INGUINAL HERNIA

O045—Laparoscopic Treatment of Incarcerated Hernias. A Systematic Literature Review

Monica Ortenzi ¹, A. Balla², E. Botteri³, F. Scolari⁴, M. Guerrieri⁵, A. Sartori⁴

¹Università Politecnica delle Marche, Clinica Chirurgica, Italy, ²Hospital “San Paolo”, UOC of General and Minimally Invasive Surgery, Italy, ³ASST Spedali Civili di Brescia PO Montichiari, General Surgery, Italy, ⁴Ospedale Di Montebelluna, Department of General Surgery, Italy, ⁵Università Politecnica delle Marche, Clinica chirurgica, Italy

Aims: Groin hernia repair can be defined as a cornerstone surgical procedure for two main reasons: it is one of the most common surgical condition and it is presumable that every surgeon would have to deal with it quite early in their career, both in the elective and emergency settings. The aim of this systematic review of the literature is to evaluate the results reported in literature about the laparoscopic approach for the treatment of acute and chronic incarcerated hernias of the groin area.

Methods: We conducted a systematic review of published articles according to the preferred reporting items for systematic review and meta-analysis (PRISMA) statement. Search was carried out in the MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library databases. Risk of bias for each included article was assessed using the Risk Of Bias In Non-randomised Studies—of Interventions (ROBIN-I) tool. Search revealed 28183 articles published between 1993 and 2021. Based on title and abstract and after duplicates removal, 77 articles were fully analysed, and 56 further articles were excluded, including 21 articles.

Results: Eight-hundred-sixteen patients were included. Of these, 408 had acute incarcerated hernia and 408 chronic incarcerated hernia. In 655 and in 161 patients laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair were performed, respectively. A total of 70 associated visceral resection were reported (5.7%). Intraoperative diagnosis and repair of contralateral hernia was performed in 25 patients (2%). Five intraoperative complications occurred (0.4%). Conversion to open surgery was required in 13 patients (1%) and postoperative complications in 64 patients (5.2%). After a mean follow up of 79.82 ± 29.57 months, recurrence after surgery was reported in three patients (0.2%)

Conclusions: Based on the present study, laparoscopy proved to be a safe and feasible approach for the treatment of both acute and chronic incarcerated hernia. Further studies are required to draw definitive conclusions about the routinely use of laparoscopy in the acute setting.

HERNIA-ADHESIONS—Abdominal Wall Hernia

O046—Novel Utilisation of Alexis® O System for Skin and Subcutaneous Tissue Retraction in Hernia and Abdominal Wall Wound Repairs

Magnus Johnston ¹, J. Khan¹, L. Martin¹, D. Wu¹, S. Zino¹

¹Ninewells Hospital UK, General Surgery, United Kingdom

Significant challenges may be encountered during open reconstructions of the abdominal wall and complex hernia repairs due to difficulty posed by relaxed, dissected subcutaneous tissues and skin obscuring the surgical field. Furthermore, this is exacerbated, in morbidly obese patient this challenge is augmented by the weight of skin and subcutaneous tissue. The result being difficulty in ascertaining adequate symmetrical exposure during abdominal wall surgery which poses an increase challenge, prolonged operative times and a none optimal use of assistants.

Aims: To present a Novel use of the Alexis® O system retractor for skin and subcutaneous tissue retraction.

Methods: The Alexis® O retractor has been used for skin and subcutaneous retraction in 6 cases: three for abdominal wall hernia repair (including one that needed a posterior component separation), three for umbilical/para-umbilical hernia and one for inguinal hernia repair.

Results: In this study the Alexis® O retractor was a useful adjunct to surgery in the three abdominal wall hernias and two umbilical hernia repairs. However, it proved difficult to place in one of the umbilical and the inguinal hernia repair due to there being inadequate available sizes. The results of this paper, presents a novel and efficient approach to skin and subcutaneous retraction by deployment of the Alexis® O—a self-expanding wound protector. The use of the Alexis® O retractor allow equal tension retraction to all points, exposing the whole surgical fields symmetrically, thus facilitating planning and unopposed moving between different positions of the surgical field without the requirement of changing retractor position. Furthermore, it allowed the freedom of the assistants hands to participate in more skilful task than retraction. The Alexis® O provided access to surgical field for both the operating and assisting surgeons, along with their instruments, without clashing with a fixed and sometimes bulky metal retractors.

Conclusions: The Alexis® O retractor can be used for skin and subcutaneous retraction to aid in the facilitation of abdominal wall closure and hernia repairs including umbilical, para-umbilical and inguinal hernias. It provides the symmetrical retraction of skin and subcutaneous tissue, freeing the surgeons and assistants and helps to avoid instrumental clashes. There could be other utilisations of the Alexis® O retractor hernia repairs if there was alternative size availability.

Keywords: Wound protector, Alexis® O, Subcutaneous tissue retraction, Hernia and abdominal wound repairs

UPPER GI—Esophageal Cancer

O048—Impact of Neoadjuvant Treatments on Totally Minimally Invasive Ivor Lewis Esophagectomy for Cancer

Francesco Puccetti ¹, L. Cinelli¹, L. Provinciali¹, A. Armienti¹, L. Barbieri¹, E. Treppiedi¹, A. Cossu¹, U. Elmore¹, R. Rosati¹

¹IRCCS San Raffaele Hospital, Gastrointestinal Surgery, Italy

Aims: Multimodal therapy represents the current gold standard for esophageal cancer care. In consideration of tumor histology and presenting staging characteristics, patients may be submitted or not to neoadjuvant chemo or chemo-radiotherapy. The present study evaluates the clinical impact of different multimodal strategies for esophageal cancer, including upfront totally minimally invasive Ivor Lewis esophagectomy (TMI-ILE), neoadjuvant chemo (FLOT) or chemo-radiotherapy (CROSS) followed by surgery.

Methods: This retrospective study analyzed a single-center series of consecutive patients undergoing TMI-ILE for cancer, from November 2017 to August 2021. All patients were multidisciplinary evaluated at the diagnosis and submitted to upfront surgery or neoadjuvant treatments, such as FLOT or CROSS regimens. The primary endpoint was postoperative morbidity, especially pulmonary and anastomotic complications. All clinical data were mined from an IRB-approved, prospectively maintained institutional database. The level of statistical significance was set at 0.05, and analyses were performed with SPSS Statistics v25.0 (IBM Corp. Armonk, NY).

Results: A total of 181 patients underwent upfront TMI-ILE (30.4%) and surgery following neoadjuvant CROSS (40.9%) or FLOT therapy (28.7%). The study population did show significantly different demographics (i.e., the median age, gender proportions, histological subtypes and pathological TNM stages), mirroring the multidisciplinary assessment criteria. The TMI-ILE after FLOT reported a significantly longer operative time and a greater lymph node harvest (p = 0.010 and < 0.001, respectively). The upfront TMI-ILE presented higher levels of postoperative morbidity due to the group composition, including more elderly and frail patients previously ruled out from complementary therapies. In the direct comparison between FLOT and CROSS regimens followed by TMI-ILE, the former showed a higher rate of pulmonary complications (p = 0,012), while no differences were found in terms of anastomotic leak.

Conclusions: Neoadjuvant chemo (FLOT) and chemo-radiotherapy (CROSS) did not involve higher chances of anastomotic leak, while pulmonary complications (i.e., pneumonia, pleural effusion, or respiratory failure) appeared to be significantly associated with FLOT regimen. Overall, patients’ characteristics (i.e., comorbidities, age, and baseline functions) demonstrated to be more relevant in terms of postoperative outcomes than the complementary treatment of choice, also proving the need for reliable preoperative risk assessment tools.

UPPER GI—Esophageal cancer

O049—Impact of Skeletal Muscle Loss During Neoadjuvant Chemoradiation on Postoperative Complications and Mortality in Oesophageal Cancer Patients

Robin Den Boer ¹, I.L. Defize¹, W.B. Veldhuis², P.A. de Jong², J.P. Ruurda¹

¹University Medical Center Utrecht, Surgery, The Netherlands, ²University Medical Center Utrecht, Radiology, The Netherlands

Aims: The aim of this retrospective cohort study is to assess body composition changes during neoadjuvant chemoradiation (nCRT) and investigate their predictive value for occurrence of postoperative complications and overall mortality.

Methods: Oesophageal cancer patients who underwent nCRT and oesophagectomy with curative intent from 2015 to 2020 and had a CT scan pre nCRT and before surgery, were included in the study. CT images were used to assess the change in skeletal muscle index (SMI), sarcopenia, subcutaneous fat index (SFI), and visceral fat index (VFI).

Results: In 146 included patients, SMI decreased significantly in both female and male subgroups (35.37 to 35.16 cm2/m2 for females, 46.59 to 44.79 cm2/m2 for males). Preoperative sarcopenia (odds ratio (OR): 0.677; 95% confidence interval (95% CI): 0.112—4.979; P value: 0.671) and percentage decrease in SMI during nCRT (OR 1.017; 95% CI 0.962—1.068; P value 0.542) did not show predictive value for total postoperative complications. Similarly, no association was seen in severe complications (sarcopenia: OR 0.582; 95% CI 0.146—2.313; P value 0.442; percentage decrease in SMI: OR 0.956; 95% CI 0,908—1.002; P value 0.058). Cox regression analysis demonstrated that percentage decrease in SMI was not associated with overall mortality (Hazard ratio (HR) 1.006; 95% CI 0.977—1.035; P value 0.669).

Conclusion(s): SMI decreased significantly during nCRT, but it was not associated with postoperative complications or overall mortality. Likewise, preoperative SMI, VFI, and sarcopenia did not show predictive value for postoperative complications and overall mortality.

UPPER GI—Gastric cancer

O050—Spade-Shaped Anastomosis After Laparoscopic Proximal Gastrectomy Using Double Suture Anchoring between the Esophagus and the Stomach (SPADE operation): A Case Series

S. Hye Park¹, Sang Soo Eom ¹, Y.-W. Young-Woo¹

¹National Cancer Center, Gastric Cancer, Korea

Aim: Various reconstruction methods following laparoscopic proximal gastrectomy (PG) have been proposed to prevent reflux. We introduced SPADE operation, a novel anastomotic method after laparoscopic PG. Technical modifications were performed and settled (Fig. 1). This report aimed to demonstrate the short-term clinical outcomes after settlement.

Methods: Data from 34 consecutive patients who underwent laparoscopic PG with SPADE between June 2017 and March 2020 were retrospectively reviewed. Reflux was evaluated based on the patients’ symptoms and 1-year follow-up endoscopy: Los Angeles (LA) classification, RGB Classification (Residue, Gastritis, Bile). Other complications were classified using the Clavien-Dindo method.

Results: The incidence of reflux esophagitis was 2.9% (1/34) (Table 2). Bile reflux was observed in six patients (17.6%), and residual food was observed in 16 patients (47.1%) in the follow-up endoscopy. Twenty-eight patients had no reflux symptoms (82.4%), while five patients (14.7%) and one patient (2.9%) had mild and moderate reflux symptoms, respectively. The rates of anastomotic stricture and ileus were 14.7% (5/34) and 11.8% (4/34), respectively (Table 3). No anastomotic leakage was observed. The incidence of major complications (Clavien-Dindo grade III or higher) was 14.7%.

Conclusions: The SPADE operation following laparoscopic PG is effective in reducing gastroesophageal reflux. Its clinical usefulness should be validated using prospective clinical trials

Table 1 Demographic and clinicopathological characteristics of patients

Variable	Value [number (%)]
Age†(year)	60.5 ± 10.7 (33–82)
BMI†(kg/m 2)	24.6 ± 2.9 (18.7–32.0)
Sex
Male	29 (85.3%)
Female	5 (14.7%)
Location of tumor
Cardia	16 (47.1%)
Fundus	2 (5.9%)
High body	16 (47.1%)
Size of tumor‡(cm)	2.0 (1.5–2.8)
Histology
WD	7 (21.2%)
MD	13 (39.4%)
PD	6 (18.2%)
SRC	7 (21.2%)
ASA score
1	10 (29.4%)
2	20 (58.8%)
3	4 (11.8%)
c T classification
cT1a	18 (52.9%)
cT1b	15 (44.1%)
cT2	1 (2.9%)
c N classification
cN0	32 (94.1%)
cN1	2 (5.9%)
c Stage
Ia	30 (88.2%)
Ib	4 (11.8%)

1. ^†Values are presented as mean ± standard deviation (range)
2. ^‡Values are presented as median (25th and 75th percentiles)
3. BMI: Body mass index; WD: well differentiated; MD: moderately differentiated; PD: poorly differentiated; SRC: signet ring cell

Table 2 Postoperative endoscopic findings and reflux symptom in 1 year follow-up

Variable	Value [number (%)]
Reflux esophagitis in EGD
No	33 (97.1%)
LA-A	0 (0%)
LA-B	1 (2.9%)
LA-C	0 (0%)
Bile reflux in EGD
Grade 0	28 (82.4%)
Grade 1	6 (17.6%)
Residual food in EGD
Grade 0	18 (52.9%)
Grade 1	3 (8.8%)
Grade 2	3 (8.8%)
Grade 3	10 (29.4%)
Reflux symptoms
No symptom	28 (82.4%)
Mild symptom	5 (14.7%)
Moderate symptom	1 (2.9%)
Severe symptom	0 (0%)

1. EGD: esophagogastroduodenoscopy; LA: The Los Angeles Classification system

Table 3 Short term outcomes of patients

Variable	Value [number (%)]
Operating time†(min)	245.4 ± 42.2 (175–340)
Estimated blood loss‡(ml)	30.0 (10.0–100.0)
Postoperative hospital stay‡(day)	7.0 (7.0–8.0)
Stage
Ia	21 (61.8%)
Ib	9 (26.5%)
IIa	3 (8.8%)
IIb	1 (2.9%)
Postoperative complications
No	25 (73.5%)
Anastomotic stricture	5 (14.7%)
Postoperative ileus	4 (11.8%)
Clavien Dindo classification
II	4 (11.8%)
IIIa	5 (14.7%)

1. ^†Values are presented as mean ± standard deviation (range)
2. ^‡Values are presented as median (25^thand 75^thpercentiles)

Fig. 1 Illustration of SPADE operation. (A) Laparoscopic D1 + proximal gastrectomy was performed. (B, C) Both distal part of posterior wall of esophagus and proximal part of anterior wall of stomach were fixed with two interrupted sutures. (D) After opening was made, one barbed continuous suture (V-Loc™) initiated at the left corner of esophagus posterior wall and stomach anterior wall, ended on the opposite right side. (E) After suturing of posterior wall anastomosis, anterior wall anastomosis was performed in the same maneuver. (F) After anastomosis was completed, spade shape is made

Fig. 2 Postoperative endoscopic finding and upper gastrointestinal series after SPADE operation. Artificial His angle and pseudo-fornix were found in postoperative endoscopy (2A) and upper gastrointestinal series (2B)

UPPER GI—Gastric Cancer

O051—Perioperative Outcomes, Survival and Quality of Life After Distal Versus Total D2-Gastrectomy: A Side-Study of the Multicenter Randomized LOGICA-Trial

R. Van Hillegersberg¹, Cas De Jongh ¹, A. Van der Veen¹, L. Brosens¹, G. Nieuwenhuijzen², J. Stoot³, J. Ruurda¹

¹University Medical Center Utrecht, Surgery, The Netherlands, ²Catharina Hospital Eindhoven, Surgery, The Netherlands, ³Zuyderland Medical Center, Surgery, The Netherlands

Background: Distal gastrectomy (DG) is selectively performed in gastric cancer patients, and may be associated with less morbidity compared to total gastrectomy (TG). However, most evidence originates from retrospective Eastern studies without neoadjuvant therapy and quality of life (QoL) assessments. This study assessed perioperative and oncological outcomes and QoL for Western gastric cancer patients undergoing DG versus TG.

Methods: This is a side-study from the randomized LOGICA-trial, which compared laparoscopic versus open D2-gastrectomy for resectable gastric cancer (cT1–4aN0–3bM0) in 10 Dutch hospitals. The randomization stratified for extent of resection (DG/TG) and hospital. DG was performed for distal/middle tumors. Proximal, diffuse and advanced tumors were treated with TG. The primary outcome was overall postoperative complications for DG versus TG. Secondary, individual complications, mortality, hospital admission, radicality, lymph node yield, 1-year survival and QoL were compared for both groups.

Results: Between 2015–2018, 211 patients underwent DG (n = 122) or TG (n = 89), and 75% of patients underwent neoadjuvant chemotherapy. Patients undergoing DG were older, had more comorbidities, less diffuse type tumors and lower cT-stage versus TG patients (p < 0,05). Patients selected for DG had lower overall complication rate (34% versus 57%; p < 0,001) compared to TG patients, which persisted (p < 0,001) after correcting for baseline differences. Anastomotic leakage, pneumonia, atrial fibrillation and Clavien-Dindo grading were lower after DG versus TG (p < 0,05), whereas other complications and 30-/90-day mortality were comparable. Median hospital and ICU-stay were shorter for DG versus TG (p < 0,05). Patients selected for DG had higher R0-resection rate (lower disease stage) compared to TG patients (p < 0,05), whereas lymph node yield was comparable (p = 0,490). After correcting for baseline differences, 1-year survival (Table 1) was similar for DG versus TG (p = 0,142). QoL (Table 2) was better after DG versus TG in 6/7 domains and 13/17 symptom scales (95% CI ≠ 1).

Conclusion: Both DG and TG are safe and effective for gastric cancer patients. For selected patients and if oncologically feasible, DG should be preferred over TG due to better perioperative outcomes and QoL, while safeguarding oncological effectiveness in this selected group. TG is a safe and effective alternative if adequate oncological control cannot be achieved with DG.

UPPER GI—Gastric cancer

O052—Impact Factors on Occurence of Occult Metastases in Staging Laparoscopy and Subsequent Therapy Change in Patients with Gastric and Gastroesophageal Junction Carcinoma

Felix von Bechtolsheim ¹

¹University Hospital Carl Gustav Carus Dresden, Department of Visceral, Thoracic and Vascular Surgery, Germany

Introduction: The accuracy of various imaging modalities used staging of gastric cancer is often poor in terms of identification of peritoneal carcinomatosis. In this regard laparoscopy is more sensitive but has certain risks of postoperative complications and is indicated mainly in patients with advanced carcinomas. The aim of this study is to identify risk factors for the occurrence of occult metastases in staging laparoscopy (SL) and, furthermore, risk factors for a change in the intention to treat after SL.

Material and Methods: This study collected and analysed clinical data from 243 consecutive patients who underwent SL as part of staging for carcinoma of the stomach and gastroesophageal junction. After exclusion of 11 patients, whose SL was performed during a re-staging process, a total of 232 patients was included in the statistical analysis regarding the occurrence of occult metastasis. After exclusion of additional patients (n = 8) whose intention to treat was changed after SL for reasons other than metastasis or inoperability, the statistical analysis was performed with the question of risk factors for a postoperative change in therapy based on 224 patients. An univariate and multivariate analysis was conducted using binary logistic regression model. Only significant results of the univariate analysis were included in the multivariate analysis. A p value < 0.05 was considered significant.

Results: Occurrence of occult metastasis correlated significantly with cT4 and cM-positive staging. Other risk factors in univariate analysis were a WHO G3 grading, diffuse, mixed, and undifferentiated Laurén subtype, and signet ring cell positive tumors. In multivariate analysis, only cM-positive staging (OR = 17.672; [95% CI: 3.060—102.052]; p = 0.001) and signet ring cell-positive histology (OR = 6.228; [95% CI: 1.151—33.716]; p = 0.034) were independent risk factors for the occurrence of occult metastasis. Significant risk factors for a change in treatment intention from curative to palliative after SL were a deep vein thrombosis, diffuse tumor localization, and diffuse, mixed, and undifferentiated Laurén subtypes, cM-positive staging, positive lymph node manifestation on EUS and UICC stage IV were significant risk factors in univariate analysis. UICC stage II and IIIA were significant as protective factors. After dichotomizing staging modalities (UICC < IIIB vs. UICC ≥ IIIB), multivariate analysis showed UICC stage IIIB and higher (OR = 7.547; [95% CI: 2.798–20.354]; p < 0.001) and diffuse, mixed and undifferentiated Laurén subtype (OR = 5.013; [95% CI: 1.696–14.822]; p = 0.001) as independent risk factors for a treatment change. Transabdominal sonography as part of staging was an independent protective factor in univariate and multivariate analysis (OR = 0.335; [95% CI: 0.115–0.972]; p = 0.044).

Conclusion: Our data suggest that sonography should be used more frequently and be an important part of the staging process in carcinoma of the stomach and gastroesophageal junction. Additionally, the results of this study might indicate that a more generous indication of staging laparoscopy, e.g., in tumor boards, might be beneficial for some patients with certain high-risk constellations (e.g. signet ring cell positivity, diffuse/mixed/undifferentiated Láuren subtype) even in presumably lower tumor stages.

SOLID ORGANS—Thyroid

O056—A RCT to Compare the Outcomes of Trans-Oral Vestibular and Axillo-Breast Approach for Endoscopic Hemithyroidectomy in Patients with Benign Thyroid Swelling

Arun Kumar ¹, A. Dhar¹

¹All India Institute of Medical Sciences, New Delhi, Department of Surgical Disciplines, India

Background: Over the last decade, endoscopic thyroidectomy has come up as a safe and feasible procedure with better cosmetic outcome due to incisions on unnoticeable areas. This randomized study compares the outcomes of two most popular approaches of trans-oral vestibular (TOETVA) and bilateral axillo-breast approach (BABA).

Methods: 136 patients were to be randomized in this study between January 2019 and November 2020 however, only 30 patients (14 in TOETVA and 16 in BABA group) were evaluated at the time of submission of this dissertation. Patients of age ≥ 18 years with benign or cytologically indeterminate lesions involving single lobe of size ≤ 5 cm were included. Primary objective was to compare the outcome in terms of patient satisfaction (cosmesis and neck discomfort) on a Likert scale of 1 to 5 at 3-months follow up.

Results: Demographic profiles were comparable among the 2 groups. The mean cosmetic scores were 1.4 ± 0.9 and 2.1 ± 0.5 and neck discomfort scores were 1.1 ± 0.3 and 1.7 ± 0.6 in TOETVA group and BABA group respectively. The results were statistically significant for both the cosmesis (p = 0.04) and neck discomfort (p = 0.01) respectively, in favour of the TOETVA approach. The mean operative time in TOETVA approach was significantly less than BABA approach (117 ± 15.6 vs 138 ± 11.5 min; p = 0.001).

Conclusion: Both the approaches were comparable in terms of complications, however TOETVA has shorter operative time besides, better patient satisfaction outcomes.

SOLID ORGANS—Parathyroid

O058—Autofluorescence Increases the Number of Parathyroid Glands Visualized and Reduces the Rate of Post-Thyroidectomy Symptomatic Hypocalcemia

L. Ross¹i, Chiara Becucci ¹, E. Pieroni¹, M. C. Vazquez¹, L. Fregoli¹, G. Materazzi¹

¹University Hospital of Pisa, Endocrine Surgery Unit, Italy

Background: Autofluorescence (AF) is a new tool that have been introduced to increase the rate of parathyroid glands identified during thyroidectomy and potentially preserve their function. This study evaluated the utility of AF to decrease the rate of hypocalcemia after thyroidectomy.

Methods: This is a randomized prospective study. Patients undergoing total thyroidectomy were randomly divided into 2 groups: Group A included patients in which AF was used to identify parathyroid glands (PGs); Control Group (Group B) included patients undergoing conventional procedure with naked eye PGs identification. Data were analyzed to compare the rate of post-operative hypocalcemia and the rate of PGs identified.

Results: A total of 200 patients were enrolled: 100 were included in Group A and 100 in Group B. In Group A, a significant higher mean number of PGs were identified by means of AF (3.83) compared to naked eye visualization of Group B (2.94) (p < 0.0001). The rate of transient hypocalcemia in Group A and Group B was 12% and 18%, respectively (p = 0.2348). The rate of symptomatic hypocalcemia in Group A and Group B was 6% and 17%, respectively (p = 0.0148). The rate of definitive hypocalcemia in Group A and Group B was 1% and 4%, respectively (p = 0.1742).

Conclusions: The use of AF may help to identify an higher number of PGs. This leads to improve the early postoperative hypocalcemia rate and the rate of definitive hypocalcemia. Besides, It significantly decrease the rate of symptomatic hypocalcemia.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O059—Index Admission Cholecystectomy Precludes the Risk of Readmission and Biliary Complication And is the Gold Standard Treatment for Biliary Colic Admissions

James Lucocq ¹, P. Patil¹, J. Scollay¹

¹Ninewells Hospital, Department of General and Upper GI Surgery, United Kingdom

Introduction: Biliary colic admissions can be managed as an index or delayed laparoscopic cholecystectomy (ILC/DLC). Opting to perform a DLC may have significant repercussions such as the risk of readmission, biliary complications (e.g. cholecystitis, pancreatitis) and pre-operative intervention (e.g. ERCP). The present study investigates the risk of readmission and additional morbidity in these patients to inform surgical decision making and reduce overall morbidity.

Method: All patients with a diagnosis of biliary colic on index admission proceeding to either ILC or DLC between January 2015 and January 2020 in one UK health board were included in the study (n = 441). The risk of being readmitted and suffering further morbidity whilst awaiting DLC is investigated. Peri-operative morbidity is compared between the readmitted versus not-readmitted groups and the emergency versus planned cholecystectomy groups.

Results: Following a biliary colic admission, the risk of emergent readmission is significant while awaiting DLC (2 months, 25%; 10 months, 48%) and high-risk groups are identified. Delaying cholecystectomy results in biliary complications (17.9%) and pre-operative intervention (6.5%). If readmitted, patients suffer a more complicated peri-operative course (longer total length of stay, longer operation times, frequent post-operative imaging and higher rates of post-operative readmission). Rates of peri-operative morbidity are comparable between emergency and planned cholecystectomy after adjusting for readmissions.

Discussion: Opting for delayed laparoscopic cholecystectomy carries a significant risk of readmission, biliary complication, and greater peri-operative morbidity. Index admission cholecystectomy obviates this risk and is the gold standard mode of treatment.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O061—Acute cholecystitis: Better Outcomes with Delayed Rather Than Emergency Laparoscopic Cholecystectomy

James Lucocq ¹, P. Patil¹, J. Scollay¹

¹Ninewells Hospital, Department of General and Upper GI Surgery, United Kingdom

Introduction: Emergency laparoscopic cholecystectomy (ELC) is advocated for acute cholecystitis (AC) as it results in a shorter length of stay, a similar conversion rate and the elimination of recurrent biliary symptoms (level 1 evidence). Nevertheless, population-level studies report higher morbidity following ELC compared to delayed LC (DLC). The primary aim of this large cohort study was to identify the operation-related adverse outcomes of ELC versus DLC. A secondary aim was to determine the rate of readmission in those patients awaiting DLC.

Methods: Patients diagnosed with AC who underwent ELC or DLC between 2015 and 2000 were included. Peri-and post-operative outcomes were compared using univariate and multivariate analysis, adjusted for pre-operative variables (demographics, inflammatory markers, previous admissions, radiological findings and pre-operative interventions). Kaplan Meier and Cox-proportional hazards models determined the rate of readmission before DLC and predictive variables.

Results: 811 patients were included in the analysis (median age, 58 years; M:F, 1:1.5; median ASA, 2). In the multivariate logistic regression, ELC was associated with increased incidences of subtotal cholecystectomy (RR 1.94; p = 0.011), intra-operative drain placement (RR 2.54; p < 0.001), prolonged post-operative length of stay (RR 7.26; p < 0.001), bile-leak ((RR 2.38; p = 0.013), post-operative imaging (OR 1.83, p = 0.006) and post operative re-admission (RR 1.90; p = 0.005). In the multivariate linear regression, ELC was associated with a short total length of stay by 1.2 days overall. There was a 10.5% risk of re-admission within two-months following discharge in patients awaiting DLC.

Conclusion: ELC is associated with a multitude of operation-related adverse outcomes compared to DLC. The potential benefit of reducing morbidity by utilising DLC should be balanced against the 10.5% risk of re-admission over two-months following discharge. Hence ELC may be the most pragmatic strategy for centres dealing with high volumes of biliary admissions especially if they have long waiting times for elective surgery. When DLC is chosen every effort should be made to ensure timely intervention to avoid the morbidity, inconvenience and expense of re-admission prior to elective operation.

HEPATO-BILIAIRY & PANCREAS—Liver

O062—Endoscopic Ultrasound Guided Biliary Drainage as a Bailout When ERCP fails

I. Sardiwalla¹, Fredrick Figueiredo ², N. Kumar¹, N.C. Kalenga¹, C. Ziady¹, M.Z. Koto¹

¹Sefako Makgatho Health Sciences University, HepatoBiliary, South Africa, ²Norway

Introduction: Patients with biliary obstruction that require biliary drainage are usually subjected to endoscopic retrograde cholangiopancreatography (ERCP). When ERCP fails the therapeutic options are percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasound guided biliary drainage (EUS –BD). EUS –BD seems to be a safe and effective means of biliary decompression after failed conventional endoscopic retrograde cholangiopancreatography. There are cost and quality of life benefits comparable with surgery and percutaneous transhepatic drainage. There are multiple approaches, stent directions, and drainage routes that are feasible.

Methods: A retrospective review of prospectively maintained database was carried out from January 2020- November 2021 was carried. All ERCPs were analysed. The subgroup where ERCP failed and EUS-BD was performed were analysed further. Primary outcomes of interest were technical success(including procedure) and post procedure adverse events. Secondary outcomes of interest included clinical success and length of hospital stay.

Results: A total of 527 ERCP’s were performed in the study period. A total of 36 ERCPs failed to achieve cannulation of the biliary tree. Of the 36 failed ERCP’s, 17 patients had attempted EUS guided extranatomic drainage (11 for malignant distal CBD obstruction), 6 for malignant hilar strictures. 2—EUS guided hot axios drainage of the CBD, 5—over the wire and conventional covered stent, 9—EUS hepaticogastrostomy, 1—failed and patient had successful PTBD. The technical success rate was 85%, post procedure adverse was observed in one patient with a GIT bleed that required transfusion. Immediate clinical success was seen in all cases and average length of hospital stay was 7 days.

Conclusion: EUS-BD undoubtedly is clinically useful as an alternative biliary drainage method. EUS-BD has acceptable morbidity and is a valuable alternative to PTBD as it allows internal drainage of bile. Further large studies are required to delineate its role better.

HEPATO-BILIAIRY & PANCREAS–Liver

O065—Introducing Minimally Invasive Liver Surgery in a Tertiary Center of Southern Switzerland: Reappraisal of the First 100 Consecutive Cases

Lorenzo Bernardi ¹, A. Cristaudi¹, R. Roesel¹, D. Christoforidis¹, P. Majno-Hurst¹

¹Ospedale Regionale di Lugano, Hepatobiliary & pancreatic Unit, Department of Surgery, Ente Ospedaliero Cantonale, Switzerland

Background/Aim: Laparoscopic liver resection (LLR) is the standard approach in selected patients affected by localized liver tumors; the advantages over open liver resection (OLR) have been clearly identified in the literature. Laparoscopic liver surgery program was implemented at our tertiary center in January 2015.

Methods: This was a retrospective analysis of consecutive patients underwent LLR since the introduction of minimally invasive liver surgery (MILS) program. Post-operative results of LLR were compared to a cohort of consecutive OLR from the same period. Cyst fenestrations were excluded from the analysis.

Results: 200 patients (LLR = 100; OLR = 100) were operated between January 2015 and September 2021. Mean age (65.4 vs. 64; p = 0.40), male sex (53% vs. 58%; p = 0.70) and previous abdominal surgery rate (72% vs. 82%; p = 0.54) were similar; incidence of chronic liver disease was significantly higher in LLR vs. OLR group (29% vs. 13%; p = 0.024). Indication to surgery was malignancy (either primary tumor or liver metastases) in 90 vs. 98% of cases (p = 0.70) and 1.7 vs. 2.8 nodules per patient, with similar size (24.0 vs. 25.0 mm, p = 0.93), were resected in LLR vs. OLR. Median operative time was shorter for LLR (315 vs. 475 min, p < 0.00001). Intraoperative transfusion rate was similar, but LLR had fewer median blood loss (200 vs. 300 ml, p = 0.01). In LLR, conversion to open surgery was 12%. Median length of hospital stay (LOS) was shorter (6 vs. 9 days, p < 0.00001) with 90-day morbidity and incidence of major complications (Clavien-Dindo ≥ 3) of 21 vs. 43% (p = 0.02) and 6 vs. 23% (p = 0.003) in LLR vs OLR respectively. 90-day mortality was 1% in each cohort. R0 rate was comparable (95 vs. 83%, p = 0.51) in LLR and OLR. In a further sub-analysis, LLR were classified in four difficulty level according to IWATE criteria (low, intermediate, advanced, expert). Advanced (n = 16) and expert (n = 18) accounted for 34% of resections. Operative time, blood loss, conversion rate and LOS increased significantly at increasing difficulty (all p < 0.05); however, 90-day morbidity and major morbidity did not. R0 rate was similar among the four groups.

Conclusions: Laparoscopic liver surgery was implemented safely with better short-term outcomes compared to those of open liver surgery.

COLORECTAL—Malignant

O066—Prolonged Interval to Surgery Following Neoadjuvant Chemoradiotherapy for Patients with Locally Advanced Rectal Cancer: A Meta-analysis of Randomized Controlled Trials

Munir Saeed ¹ , P. Owens¹, S. Sahebally¹, B. Murphy¹, P. Shokuhi¹, N. McCawley¹, P. Loughlin¹, J. Burke¹, D. McNamara¹

¹Beaumont Hospital Dublin Ireland, Colorectal, Ireland

Background: Neoadjuvant chemoradiotherapy (NCRT), followed by total mesorectal excision (TME) after an interval of 6-8 weeks, represents the standard of care for patients with locally advanced rectal cancer (LARC). Increasing this interval may improve rates of complete pathological response (pCR) and tumour downstaging. We performed a meta-analysis comparing standard (SI) versus longer interval (≥ 8 weeks) after NCRT to surgery for LARC.

Methods: A PRIMSA-compliant meta-analysis was performed after searching PubMed, Embase, and Cochrane databases up to January 2022. All randomized controlled trials (RCTs) comparing SI with LI after NCRT for LARC were included. The primary endpoint was pCR rate. Secondary endpoints included rates of R0 resection, circumferential resection margin positivity (+ CRM), TME completeness, lymph node yield (LNY), local recurrence (LR), operative duration, tumour downstaging (TD), sphincter preservation, mortality, postoperative complications, surgical site infection (SSI) and anastomotic leak (AL). Random effects models were used to calculate pooled effect size estimates.

Results: Five RCTs encompassing 923 patients were included. There was no difference between SI and LI in terms of pCR (OR 0.80, 95%CI = 0.49-1.28, p = 0.35). The SI group was associated with a shorter duration of surgery (MD -28.53, 95%CI = -55.54–1.52, p = 0.04) and appeared to favour sphincter presevation (OR 1.41, 95%CI = 1.00-1.98, p = 0.05) whereas rates of TD were higher in the LI group (OR 0.69, 95%CI = 0.47-1.01, p = 0.05). There was no difference in R0 resection rates (OR 0.85, 95%CI = 0.51-1.42, p = 0.54), + CRM (OR 1.36, 95%CI = 0.62-2.98, p = 0.45), LR (OR 0.83, 95%CI = 0.41-1.68, p = 0.61), incomplete TME (OR 0.86, 95%CI = 0.25-2.95, p = 0.81), LNY (MD -0.37, 95%CI = -1.64-0.90, p = 0.57), AL (OR 1.46, 95%CI = 0.86-2.47, p = 0.16), mortality (OR 2.08, 95%CI = 0.44-9.96, p = 0.36) or surgical complications (OR 1.23, 95%CI = 0.61-2.48, p = 0.57) between SI and LI.

Conclusions: A LI to surgery after NCRT for LARC may increase TD but is associated with a prolonged duration of surgery. There were no differences in rates of pCR, + CRM, LR, LNY, AL or mortality between SI and LI groups.

HERNIA-ADHESIONS—Emergency Surgery

O067—The Use of Fluorescence Angiography to Assess Bowel Viability in the Acute Setting: An International, Multi-centre Experience

Hanneke Joosten ¹, G. Longchamp², M. Khan³, W. Lameris¹, M. van Berge Henegouwen¹, W. Bemelman¹, R. Cahill³, R. Hompes¹, F. Ris⁴

¹Amsterdam UMC, Surgery, The Netherlands, ²University Hospitals of Geneva, Division of Digestive Surgery, Switzerland, ³Mater Misericordiae University, Department of Surgery, Ireland, ⁴University Hospitals of Geneva, Division of Digestive Surgery, Switzerland

Introduction: Assessing bowel viability can be challenging during acute surgical procedures, especially when it comes to mesenteric ischaemia. Intraoperative fluorescence angiography (FA) may be a valuable tool for the surgeon to determine whether bowel resection is necessary, and to define the most appropriate resection margins. The aim of this study is to report on the use of FA in the acute setting and to judge its impact on intraoperative decision making.

Materials and Methods: This is a multi-centre, retrospective cohort study of patients that underwent FA-guided emergency abdominal surgery between February 2016 and February 2021 in three colorectal units where intraoperative FA was performed to assess bowel viability. Primary endpoint was change of management in surgical strategy after the FA assessment.

Results: A total of 93 patients (50 males, 66.6 ± 19.2 years, ASA score > III in 85%) were operated on in the acute setting. Surgical approach was laparotomy in 66 (71%) patients and laparoscopy in 27 (29%) of which seven (25%) were converted. The most common aetiologies were mesenteric ischaemia (n = 42,45%) and adhesional/herniae-related strangulation (n = 41, 44%). In 50 patients a bowel resection was done. Overall rates of anastomosis after resection, reoperation and 30-day mortality were 48% (24/50, one leak), 12% and 18% respectively. FA changed management in 27 (29%) patients. In four patients, resection was avoided(see Fig. 1 for an example)and in 21 (23% overall) extra bowel length was preserved (median 50 cm of bowel saved, IQR 28-98) although three patients developed further ischaemia. In six (5%) patients an extended resection (median of 20 cm, IQR 6-50 extra bowel) was prompted.

Conclusion: In patients operated for bowel ischaemia the intraoperative use of FA preserved bowel in approximately one out of four patients but care is needed in its interpretation. These preliminary results warrant further prospective studies of this promising technology.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O069—Early Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy Followed by Delayed Laparoscopic Cholecystectomy in Patients with Grade II Acute Cholecystitis

Mostafa Refaie Abdelatty Elkeleny ¹, H. Elhadad¹, M. Seifeldeen²

¹Faculty of Medicine,Alexandria University, General Surgery Department, GIT Unit, Egypt, ²Alexandria University, General Surgery Department, Egypt

Background: In the past, the majority of acute cholecystitis (AC) patients were conservatively treated. Strong evidence from multiple reports demonstrating that laparoscopic cholecystectomy (LC) is safe and should be used as a first-line treatment has transformed this paradigm. But this statement cannot be applied to all grades of AC. The purpose of this study was to compare the two recommended approaches by the Tokyo guidelines in grade II acute cholecystitis as regard the early operative outcome.

Methods: The medical records of all patients with grade II acute cholecystitis according to the stated criteria were reviewed retrospectively. Those who were subjected to either early laparoscopic cholecystectomy (group A, n = 130) and those who received percutaneous cholecystostomy first and subsequent LC (group B, n = 90) were compared.

Results: Both groups were comparable as regards the parameters of Tokyo classification. There were significant differences in baseline data, operative difficulties and post-operative complications. Cholecystostomy-related complications were found in 7 patients. The conversion rate in both groups was 25% and 5%, respectively; while the intraoperative biliary injury was 10% and 2.2%, respectively. In group A, 92% of those with biliary injury and 80% of those converted to open surgery; had evidence of localized inflammation around the gallbladder.

Conclusion: In selected patients with grade II acute cholecystitis associated with higher risks, placement of percutaneous cholecystostomy is beneficial in avoiding the life-threatening consequences. A two-month delay between the time of PC and the subsequent LC is suggested. In general, LC after PC was easier than early LC. Local inflammatory changes including empyema were associated with higher complications rate in early LC group.

ROBOTICS & NEW TECHNIQUES—Technology

O070—Evaluation of Inter-user Variability in Indocyanine Green Fluorescence Angiography to Assess Gastric Conduit Perfusion in Oesophageal Cancer Surgery

Hanneke Joosten ¹, N. Hardy², J. Dalli, R. Hompes¹, R. Cahill³, M. Van Berge Henegouwen¹

¹Amsterdam UMC, Surgery department, The Netherlands, ²UCD Centre for Precision Surgery, Surgery, Ireland, ³Mater Misericordiae University Hospital, Surgery, Ireland

Indocyanine Green Fluorescence Angiography (ICGFA) has been deployed to tackle malperfusion-related anastomotic complications. This study assesses variations in operator interpretation of pre-anastomotic ICGFA inflow in the gastric conduit.

Methods: Utilising an innovative online interactive multimedia platform (Mindstamp), oesophageal surgeons completed a baseline opinion-practice questionnaire and proceeded to interpret, and then digitally assign, a distal transection point on 8 ICGFA videos of oesophageal resections (6 Ivor Lewis, 2 McKeown). Annotations regarding gastric conduit transection by ICGFA were compared between expert users versus non-expert participants using ImageJ to delineate longitudinal distances with Shapiro Wilk and t-tests to ascertain significance. Expert versus non-expert correlation was assessed via Intra-classCorrelation Coefficients(ICC).

Results: Thirty participants (thirteen consultants, six ICGFA experts) completed the study in all aspects. Of these, a high majority (29) stated ICGFA should be used routinely with most (21, including 5/6 experts) stating that 11-50 cases were needed for competency in interpretation. Among users, there were wide variations in dosing (0.05-3 mg/kg) and practice impact. Agreement regarding ICGFA video interpretation concerning transection level (Fig. 1, experts represented by red dots, non-experts blue dots) among experts was “moderate” (ICC = 0.717) overall but “good-excellent” (ICC = 0.871) among seven videos with leave-one-out exclusion of the video with highest disagreement. Agreement among non-experts was moderate (ICC = 0.641) overall and in every subgroup including among consultants (ICC = 0.626). Experts choose levels that preserved more gastric conduit length versus non-experts in all but one video(p = 0.02).

Conclusion: Considerable variability exists with ICGFA interpretation and indeed impact. Even adept users may be challenged in specific cases. Standardised training and/or computerised quantitative fluorescence may help better usage.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

O071—Safe Management of Laparoscopic Surgery in the Age of COVID-19: Pre-clinical Investigation of Abdominal Gas Leakage from Surgical Trocar And development of New Preventive

Yoshinori Hayashi ¹, Y. Ishii¹, T. Ishida¹, T. Saito², K. Yamashita², K. Tanaka², T. Makino², K. Yamamoto², T. Takahashi², Y. Kurokawa², H. Eguchi², Y. Doki², K. Nakajima¹

¹Graduate School of Medicine, Osaka University, Department of Next Generation Endoscopic Intervention, Department of Gastroenterological Surgery, Japan, ²Graduate School of Medicine, Osaka University, Department of Gastroenterological Surgery, Japan

Background: With the COVID-19 pandemic, the risk of viral exposure to healthcare workers via Aerosol Generating Procedures including laparoscopic surgery, has been re-recognized. In laparoscopic surgery it is known that gas leakage occurs when a pressurized closed cavity (abdominal cavity) is intentionally opened, such as during trocar removal or specimen retrieval, but has not been studied in detail about possible gas leakage through surgical trocars themselves during surgical manipulation such as forceps exchange.

Aims: The aims of this study were: 1) to visually confirm the presence of leakage of insufflated gas from surgical trocars, 2) to measure and elucidate the scales of gas leakage in various intra-abdominal pressure settings, and ultimately, 3) to develop new preventive device.

Methods: We used porcine pneumoperitoneum model (female, 25-30 kg, n = 3). A standard 5-mm grasping forceps was used with various types of 12-mm trocars. The gas leakage during the insertion/removal of forceps, if any, was imaged and recorded using Schlieren optical system (model SS100, Kato Koken Co., Ltd., Tokyo, Japan), which visualizes minute changes in gas-flow that are invisible to the naked eye, by using differences in the density and refractive index of the medium. The gas leakage velocity (GLV) and gas leakage area (GLA) were then calculated from the captured images using image analysis software (Image J ver. 1.53e, National Institutes of Health, Maryland, USA). Measurements were taken in five trials under different insufflation pressures between 8 and 14 mmHg.

Results: In any types of trocars, a substantial leakage was observed at the inlet during forceps insertion/removal. Both GLV and GLA increased as the intra-abdominal pressure was raised, but for GLV, a plateau was observed at 12 mmHg. These gas leakages disappeared after the forceps were fully inserted into the abdominal cavity, and were no longer observed during forceps manipulation. Based on these results, we have started to develop a detachable gas collection device using continuous low-pressure suction on trocar head housings.

Conclusion: We confirmed the substantial gas leakage from trocars during forceps insertion/removal. The gas leakage increased as the intra-abdominal pressure was raised. A new gas collection system is now under development with industries.

ROBOTICS & NEW TECHNIQUES—Basic and Technical Research

O072—Comparing Real-time Quantification of Tissue Perfusion Using Laser Speckle Contrast Imaging To Laser Doppler Imaging in Porcine Intestinal Anastomosis

Yao Liu ¹, S. Mehrotra², V. Buharin³, J. Oberlin³, M. Marois³, C. Nwaiwu¹, N. Bouvy⁴, P. Kim¹

¹Brown University—Rhode Island Hospital, Surgery, USA, ²University of Buffalo, Surgery, USA, ³Activ Surgical, USA, ⁴MUMC, Surgery, The Netherlands

Aims: Perfusion differences between antimesenteric/mesenteric bowel regions may contribute to anastomotic leaks. Current perfusion assessment methods such as ICG angiography lack spatial resolution and objectivity to define such perfusion differences. We have previously demonstrated that Laser Speckle Contrast Imaging (LSCI) detects real-time tissue blood flow and displays both detailed perfusion colormaps and numerical quantification. Herein, we validate a novel LSCI perfusion quantification feature against blood pressure variation and laser doppler imaging (LDI) in a porcine intestinal anastomosis model.

Methods: ActivSightTM (Activ Surgical, Boston, MA) is an FDA-cleared device combining LSCI and ICG fluorescence imaging in laparoscopic form factor. LSCI detects tissue blood flow by capturing coherent laser light scatter from red blood cells in microcirculation. A prototype LSCI feature quantifies tissue perfusion in relative perfusion units (RPUs) as a percentage relative to referenced perfused/ischemic tissue. A stapled, side-to-side, antimesenteric ileocolic anastomosis was created in a porcine model (Fig. 1A), and tissue perfusion measured using LSCI (ActivSightTM) and LDI (Moor Technologies, Wilmington, DE). The ileocolic anastomotic site perfusion was examined under conditions of progressive aortic inflow and portal venous outflow occlusions. RPUs were calculated using LSCI/LDI perfusion colormaps (Fig. 1B/1C). Mean arterial pressure (MAP) was measured via femoral arterial line.

Results: LSCI perfusion correlated strongly with LDI (Pearson’s coefficient .788, Fig. 2A) and MAP (Pearson’s .968/.950 for arterial/venous models). Without vascular occlusion, ileum demonstrated higher perfusion values than colon (RPU 92.9% vs 67.6%, p = .0104) along the ileocolic anastomosis (Fig. 2B). LSCI quantified intestinal ischemia from both aortic inflow and portal venous outflow obstruction with a similar magnitude decrease in RPU values across ileum and colon (Fig. 2C/2D). With aortic clamping, the antimesenteric region of ileum showed lower perfusion than the mesenteric region (RPU 44.7% vs 55.3%, p = .0113) though ileal perfusion differences were not statistically significant with portal venous clamping (p = .0664).

Conclusions: LSCI provides real-time tissue perfusion colormap and quantification validated with LDI and physiologic blood pressure variation. The intestinal anastomosis demonstrated similar ischemia in response to both arterial inflow/venous outflow occlusion. In addition, mesenteric/antimesenteric bowel regions displayed perfusion differences in both arterial and venous control.

ROBOTICS & NEW TECHNIQUES—Technology

O075—A Call for the Paradigm Shift: Implementation of Laparoscopic Intraoperative Ultrasound in General Surgery, as a Transition from the Use in HPB SURGERY

Andrei Keidar ¹, I Carmeli¹

¹Assuta Ashdod Hospital, Surgery, Israel

Background: laparoscopic ultrasound (LUS) is an underutilised modality, and while many surgical specialties adopted its use by the operating surgeon, general surgery was sluggish in its implementation

Objective to describe the process of learning the intraoperative use of laparoscopic US (L-IOUS) the hepatopancreatobiliary surgery and in general surgery.

Methods: This retrospective review includes selected cases of intraoperative use of laparoscopic ultrasound during surgery in our institution between 2018 and 2021. The reported outcomes were the indications and correlation with the preoperative imaging (US, CT, EUS, MRI) and postoperative pathologic findings.

Results: The series included HPB cases ( Whipple operations, multitude of intraoperative cholangiography correlated with L-IOUS in 19 cases of CBD exploration, liver resections, etc.) and standard general surgery procedures assisted by L-IOUS. Besides others, LIOUS identified the precise diagnosis in 95% of the cases in choledocholithiasis, in 80% of the pancreatic tumors, cysts, or autoimmune pancreatitis, guided the biopsy of the tumors located close to deep vascular structures, assisted in the abscess drainages, assured patency of named blood vessels during organ resections. The finding were confirmed by intraoperative biopsy or postoperative pathology.

Conclusions: We call for wider implemention of L-IOUS in a general surgery practice. It appears to effectively assist the intraoperative diagnosis. It is a handy, risk free, fast, but underused modality, and could be implemented more prevalently. Representative video cases with clinical correlation will be presented.

ROBOTICS & NEW TECHNIQUES—Technology

O076—A Nationwide Survey on the Perceptions of General Surgeons on Artificial Intelligence

Frank Voskens ¹, J.R. Abbing¹, A.T. Ruys², J.P Ruurda³, I.A.M.J Broeders¹

¹Meander Medical Center, Department of Surgery, The Netherlands, ²Elisabeth TweeSteden Ziekenhuis, Department of Surgery, The Netherlands,³University Medical Center, Department of Surgery, The Netherlands

Aim: Artificial intelligence (AI) has the potential to improve perioperative diagnosis and decision making. Despite promising study results, the majority of AI platforms in surgery currently remain in the research setting. Understanding the current knowledge and general attitude of surgeons toward AI applications in their surgical practice is essential and can contribute to the future development and uptake of AI in surgery.

Methods: In March 2021, a web-based survey was conducted among members of the Dutch Association of Surgery. The survey measured opinions on the existing knowledge, expectations, and concerns on AI among surgical residents and surgeons.

Results: A total of 313 respondents completed the survey. Overall, 85% of the respondents agreed that AI could be of value in the surgical field and 61% expected AI to improve their diagnostic ability (Fig. 1). The outpatient clinic (35.8%) and operating room (39.6%) were stated as area of interest for the use of AI. Statistically, surgeons working in an academic hospital were more likely to be aware of the possibilities of AI (P = 0.01). The surgeons in this survey were not worried about job replacement, however they raised the greatest concerns on accountability issues (50.5%), loss of autonomy (46.6%), and risk of bias (43.5%).

Conclusion: This survey demonstrates that the majority of the surgeons show a positive and open attitude towards AI. Although various ethical issues and concerns arise, the expectations regarding the implementation of future surgical AI applications are high.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

O077—Optimal Usage of Very-Low-Voltage Electrosurgical Technology

Yuki Ushimaru ¹, K. Akeo², M. Hosaka³, K. Yamashita⁴, T. Saito⁴, K. Tanaka⁴, T. Makino⁴, K. Yamamoto⁴, T. Takahashi⁴, Y. Kurokawa⁴, H. Eguchi⁴, Y. Doki⁴, K. Nakajima¹

¹Osaka University, Department of Next Generation Endoscopic Intervention, Japan, ²AMCO Inc., Japan, ³Yamashina Seiki Co. Ltd., Japan, ⁴Osaka University, Department of Gastroenterological Surgery, Japan

Background: The very-low-voltage (VLV) mode in electrocautery stably and deeply energizes the tissue even though the local electrical resistance changes with the energization. Therefore, VLV is considered a more reliable cauterization method than other coagulation modes. In clinical practice, VLV has been empirically shown that an appropriate combination of saline drops and blood aspiration can further enhance coagulation ability, but the detailed mechanism is not known. The aims of this study were: 1) to evaluate the relationship between cauterization time (CT) and cauterization distance (CD) under VLV mode, and 2) to verify how the addition of suction or saline-dripping affects the power consumption and CD.

Methods: Twelve pigs (female, 35 kg) were enrolled in the experiment. A liver hemorrhage model was prepared under an open abdomen, and hemostasis was attempted on the hemorrhage lesion using VLV mode under various conditions (coagulation time: 3, 6, 9, 12 s, with/without saline drops and/or continuous suction). Electrical data (voltage, current, resistance) were extracted during cauterization. After cauterization, the vertical/horizontal extent of thermal damage, i.e. CD, was measured, and success or failure of hemostasis was recorded.

Results: The vertical/horizontal CD, the power consumption, and the integrated current value positively correlated with the cauterization time. The depth of coagulation deepened with the saline drops (p < 0.01), but was not affected by the continuous suction (p = 0.20). The cauterized area became larger with the saline drops (p < 0.01), but smaller with the suction (p < 0.01). Both power consumption and integrated current increased with the saline drops (p < 0.01) and decreased with the suction (p < 0.01). The success rate of hemostasis decreased with the saline drops alone (31 successes /48 trials (success rate = 64.5%) in the saline drops group, 44/48 (91.7%) in the control group), but improved with the continuous suction (45/48 (93.8%)).

Conclusion: We found a positive correlation between CT and CD. Saline drops increased the heat transfer efficiency but decreased the success rate of hemostasis. The addition of continuous suction increased the hemostatic efficiency.

ROBOTICS & NEW TECHNIQUES—Solid organs

O078—Time to Endoscopic Vacuum Therapy—Lessons Learned After > 150 Robotic Assisted Minimally Invasive Esophagectomies (RAMIE) at a German High-Volume Center

Dolores Müller ¹ , R. Stier¹, B. Babic¹, S. H. Chon¹, L. Schiffmann¹, W. Schröder¹, C. Bruns¹, H Fuchs¹

¹University of Cologne, Department for General, Visceral, Cancer and Transplant Surgery, Germany

Introduction/Aim: Intrathoracic anastomotic leak after Ivor Lewis esophagectomy depicts one of the most severe and early postoperative complications and is considered a benchmark for the quality of the esophagectomy. For treatment of ECCG type II leaks, either self-expanding metal stents (SEMS) can be placed or endoscopic vacuum therapy (EVT) can be applied, however, to date there is no prospective data concerning the optimal endoscopic treatment strategy. The aim of the study was to report outcomes of treatment strategies for patients with an ECCG type II anastomotic leak after robotic assisted minimally invasive esophagectomy (RAMIE).

Methods: Analysis of our prospectively collected, IRB approved database of robotic esophagectomies was performed. Starting 01/2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for RAMIE cases at our academic center. All patients that developed an ECCG type II anastomotic leak since the introduction of robotic assisted surgery at our high volume center (> 200 cases/year) were included in the analysis. Time to EVT, duration of EVT, and follow up treatments were analyzed for all patients.

Results: Sine 2017 a total of 157 patients underwent a robotic assisted Ivor Lewis esophagectomy at our clinic. Twenty-three patients developed an ECCG type II anastomotic leak (14.6% leak rate). Successful completion was achieved in 21/23 of cases (91%). Two patients were deceased prior to the completion of endoscopic therapy, one of unrelated Covid-19 pneumonia and one of sepsis with unknown focus. Mean duration of EVT was 12 days (range 4-28 days) with a mean of 2 endoscopic sponge changes (range 0-5). Anastomotic leak was diagnosed at a mean of 9 days post-surgery (range 2-19 days). Placement of a SEMS was performed in 5 patients (24%) after completion of EVT. EVT needed to be reestablished in 2 patients after initial completion. No patient needed conversion to surgical therapy, however preemptive EVT was performed after surgical revision in 3 patients (37.5%) with an ECCG type III leak. The closure was confirmed in all patients by endoscopy or by CT scan with oral contrast or a contrast swallow before the beginning of oral intake

Conclusion: EVT has been shown to be a safe and successful treatment option for anastomotic leaks after robotic assisted esophagectomy with success rates of 91% in our cohort. No additional surgical revision was performed in any patient, emphasizing the efficacy of the technique.

COLORECTAL—Benign

O079—Surgeons' Attitudes During Laparoscopic Appendectomy: Do Subjective Intraoperative Assessments Affect the Choice of Peritoneal Irrigation?

Stefano Piero Bernardo Cioffi ¹, S. Granieri², M. Altomare¹, A. Spota¹, F. Virdis¹, R. Bini¹, O. Chiara¹, S. Cimbanassi¹

¹ASST GOM Niguarda, General Surgery-Trauma Team, Italy, ²Ospedale di Vimercate, General Surgery, Italy

Aims: Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most commonly performed procedures. Complicated appendicitis (CA), gangrenous or perforated, can be a true challenge regardless of experience. The impact of different approaches on LA has been studied. Nevertheless, the effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared. To date, many articles reported clinical evidence of benefit from avoiding PL during LA in reducing the postoperative risk of abscess, wound infection, and operative times. Nevertheless, all recent meta-analyses failed to show a statistical advantage for PL during LA on the postoperative abscess, mainly due to study heterogeneity. This study aims to investigate surgeons’ perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons’ subjectivity influences the decision-making process on PL.

Methods: Data were extracted from a two-year data lock on REsiDENT-1 registry. REsiDENT-1 is a prospective resident-led multicenter observational trial that started in October 2019, ClinicalTrials.gov Identifier: NCT05075252. This study investigates the relationships between PL and postoperative intraabdominal abscesses introducing a classification for AA to standardize the intraoperative (IOp) grading, focusing on IOp appendix aspect and peritoneal contamination. The registry includes pre, intra, and postoperative variables. We applied our classification proposal and used a five-point Lickert scale (Ls) to assess subjective LA difficulty. We ran a concordance analysis between the IOp evaluation of AA and histology. Subsequently, we built a multivariate logistic regression model to identify factors influencing PL, including data of the IOp assessment, the Ls, and clinical data. We defined PL as irrigation with more than 500 ml.

Results: Five hundred sixty-one patients were enrolled until October 2021. We recruited twenty hospitals and 51 residents. Five hundred forty-two procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 207 LA (38,2%). We discovered a significant moderate monotonic relationship between surgical evaluation and histology, p < 0.001. The reliability of the surgeon’s IOp assessment of appendicitis is progressively lower for CA (Figs. 1–2). We identified the presence of a single abscess, localized purulent peritonitis, diffuse purulent peritonitis, IOp CA, difficulty level 2,3, and 4 as independent predictors for PL.

Conclusions: This study shows how surgeons' evaluation of AA severity overestimated more than half of CA with the perception of a challenging procedure (Fig. 2) These perceptions were among the influencing factors for PL. We demonstrated that IOp evaluation during LA could be affected by subjectivity with a non-negligible impact on operative attitudes, driving surgeons away from evidence-based choices.

UPPER GI—Gastric Cancer

O080—Open Versus Laparoscopic Gastrectomy for Advanced Gastric Cancer: Propensity Score: Matching Analysis of Survival by the Italian Research Group of Gastric Cancer (GIRCG)

Pietro Maria Lombardi ¹, S. Giacopuzzi², R. Rosati³, U. Fumagalli Romario⁴, G.L. Baiocchi⁵, D. Marrelli⁶, P. Morgagni⁷, C. Castoro⁸, M. De Giuli⁹, A. Biondi¹⁰, F. Rosa¹¹, S. Rausei¹², S. Molfino¹³, J. Viganò¹⁴, A. Peri¹⁵, F. Cianchi¹⁶, M. Catarci¹⁷, M. Berselli¹⁸, S. Olmi¹⁹, S. Santi²⁰, G. Ferrari²¹

¹Niguarda Cancer Center/IRCCS Humanitas Research Hospital, Division of Minimally-Invasive Surgical Oncology/Unit of Foregut Surgery, Italy, ²General and Upper GI Surgery Division, University of Verona, Italy, ³San Raffaele Hospital IRCCS, Department of Gastrointestinal Surgery, Italy, ⁴European Institute of Oncology, Digestive Surgery, Italy, ⁵ASST Cremona, Department of Surgery, Italy, ⁶Policlinico le Scotte, University of Siena, Department of Surgery, Italy, ⁷General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Department of Surgery, Italy, ⁸IRCCS Humanitas Research Hospital, Unit of Foregut Surgery, Italy, ⁹San Luigi University Hospital, University of Turin, Department of Oncology, Surgical Oncology and Digestive Surgery Unit, Italy, ¹⁰Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Dipartimento di Scienze Mediche e Chirurgiche, Italy, ¹¹Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Digestive Surgery, Italy, ¹²ASST Valle Olona, Department of Surgery, Italy, ¹³Surgical Unit, University of Brescia, Department of Experimental and Clinical Sciences, Italy, ¹⁴IRCCS Policlinico San Matteo, Pavia, General Surgery, Italy, ¹⁵University of Pavia and Fondazione IRCCS Policlinico San Matteo, Department of Surgery, Italy, ¹⁶Digestive Surgery Unit, Careggi Hospital, Department of Experimental and Clinical Medicine, University of Florence, Italy, ¹⁷Sandro Pertini Hospital, ASL Roma, General Surgery Unit, Italy, ¹⁸ASST Sette Laghi, General Surgery Department, Italy, ¹⁹San Marco Hospital GSD, Zingonia, Department of General and Oncologic Surgery, ²⁰Azienda Ospedaliero-Universitaria Pisana, Division of Esophageal Surgery, Italy, ²¹Niguarda Cancer Center, Niguarda Hospital, Minimally Invasive Surgical Oncology Unit, Italy

Background: Oncologic outcomes after laparoscopic gastrectomy (LG) in advanced gastric cancer (AGC) in the West are poorly investigated. The study analysed data of patients undergoing curative-intent distal or total gastrectomy with D2 lymphadenectomy for AGC by either LG or open (OG) gastrectomy performed in 20 institutions belonging to the Italian Research Group on Gastric Cancer.

Methods: Data were gathered between 2015 and 2018 and retrospectively analysed. Propensity Score

Matching (PSM) analysis was performed in order to balance baseline characteristics of LG and OG patients. The primary endpoint was 3-year overall survival (OS). Secondary endpoints were 3-year disease free survival (DFS) and short-term outcomes. Multivariable regression analyses for OS were conducted.

Results: Of the 717 patients included, 438 patients were correctly matched after PSM, 219 in each group. The 3-year OS rate was 73.6% and 68.7% in the LG and OG group respectively (p = 0.4) (Fig. 1). When compared with OG, LG showed comparable 3-year DFS (62.8%, vs 58.9%p = 0.4), higher rate of adjuvant chemotherapy (ACT) accomplishment (56.9% vs 40.2%, p = 0.001), similar rates of 30-day morbidity, mortality and readmission rates. Factors associated with OS were ASA Score ≥ 3, age-adjusted Charlson Comorbidity Index (aCCI) ≥ 5, lymph node ratio (LNR) ≥ 0.15, p/ypTNM Stage III and performed adjuvant chemotherapy (ACT) (Table 1).

Conclusions: LG for AGC offers similar rates of OS when compared to OG. In addition, LG is associated with higher rates of accomplishment of ACT and comparable short-term outcomes and DFS.

BARIATRICS—Laparoscopic

O082—Reoperative Bariatric Surgery After Primary Laparoscopic Gastric Plication for Morbid Obesity: A Systematic Review and Meta-analysis

Francesco Mongelli ¹, Z. Horvath¹, M. Marengo², F. Volontè³, D. La Regina¹, R Peterli⁴, F. Garofalo⁵

¹Ospedale Regionale di Bellinzona, Surgery, Switzerland, ²Ospedale di Locarno, Surgery, Switzerland, ³Clinica Sant'Anna di Lugano, Surgery, Switzerland, ⁴Clarunis—University Center for Gastrointestinal and Liver Diseases, Surgery, Switzerland, ⁵Ospedale Regionale di Lugano, Surgery, Switzerland

Background: Laparoscopic gastric plication (LGP) often requires reoperative bariatric surgery (RBS) due to complications and insufficient weight loss. The aim of our study was to assess perioperative morbidity and weight loss during follow-up in patients undergoing RBS after primary LGP for morbid obesity.

Methods: A search of PubMed, Web of Science, Cochrane Library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using ("conversion"OR"revision*"OR"reoperat*")AND("gastric"OR"curvatur*")AND"plication". Studies were deemed eligible if data on RBS after LGP were provided. For each study, data were extracted and analyzed.

Results: In the literature review, 291 articles were screened and 7 included. The studies covered a total of 367 patients, of whom 119 received a sleeve gastrectomy (SG), 85 a Roux-en-y gastric bypass (RYGB), 75 a one anastomosis-gastric bypass (OAGB), 45 a re-LGP, and 25 a jejuno-ileal bypass. After RBS, excess weight loss was 50.8 ± 6.5% at 6 months, 71.0 ± 7.7% at 12 months, and 89.0 ± 7.8% at 24 months. Operative time was 101.3 ± 14.6 min. Postoperatively, 18/255 patients (7.1%) had a complication, and leakage and reoperations were reported in 6/255 (2.4%) and 5/255 (2.0%) patients, respectively. Length of hospital stay was 3.1 ± 2.4 days. The quality of evidence was rated as “very low”.

Conclusions: Despite limitations, this systematic review and meta-analysis showed that RBS after LGP has an acceptable rate of complications and is effective in terms of excess weight loss during follow-up. No specific operation (e.g., SG, RYGB, OAGB) can be suggested over another due to the lack of evidence.

BARIATRICS—Laparoscopic

O083—Intermediate-Term Outcomes of Laparoscopic Gastric Plication, Single Center Experience

Mohamed Abdelgawad ¹, A. Elgeidie¹, M. Elrefei¹, E. Abou El-Magd¹

¹Gastrointestinal Surgical Center (GISC), Faculty of Medicine, Mansoura University, Egypt, Department of General Surgery, Egypt

Background: Although laparoscopic gastric plication has been mentioned in many studies, its practice has not yet been standardized. In addition, the outcomes remain conflicting. This study was conducted to elucidate the intermediate-term outcomes of laparoscopic gastric plication procedure.

Patients and Methods: We included a total of 31 patients in this retrospective cohort study. They were subjected to the routine preoperative preparation prior to the gastric plication procedure. Regular follow-up visits were scheduled at 1, 3, 6, 12, 24 and 36 months postoperatively. Weight loss, comorbidity resolution and failure rate were our main outcomes.

Results: The mean duration of operation was 162.58 min and the duration of hospitalization had a mean value of 2.32 days. Both weight and BMI showed a significant decrease compared to the baseline values (p < 0.001). EBWL had mean values of 47.97%, 61.9% and 77.65% at 12-, 24- and 36-month follow up visits respectively. Failure was detected in nine cases (29%), and all of them were managed by revisional bariatric procedures. Post-operative de novo GERD showed a significant increase in its incidence compared to the baseline value.

Conclusion: Despite good weight loss outcomes, gastric plication was associated with a high failure rate. It should be considered for individuals with the potential for continued diet and activity after surgery, a BMI of less than 45 kg/m2, and early type 2 diabetes.

BARIATRICS—Laparoscopic

O084—Laparoscopic Bariatric Surgery for patients with BMI over 50—A Survey of 789 Bariatric Surgeons

Panagiotis Lainas ¹, M. Kermansaravi², S. Shahabi Shahmiri³, W. Yang⁴, A. Davarpanah Jazi⁵, R. Villalonga⁶, L. Antozzi⁷, P. Parmar⁸, R. Kassir⁹, S. Chiappetta¹⁰, L. Zubiaga¹¹, A. Vitiello¹², K. Mahawar¹³, M. Carbajo¹⁴, M. Musella¹⁵, S. Shikora¹⁶

¹Metropolitan Hospital of Athens, HEAL Academy, Athens, Department of Digestive Surgery, Greece, ²Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Division of Minimally Invasive and Bariatric Surgery, Iran, ³Iran University of Medical Sciences, Tehran, Minimally Invasive Surgery Research Center, Iran, ⁴The First Affiliated Hospital of Jinan University, Guangzhou, Department of Metabolic and Bariatric Surgery, China, ⁵Shariati Hospital, Isfahan, Department of General Surgery, Iran, ⁶Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Endocrine, Metabolic and Bariatric Unit., Department of General and Digestive Surgery, Spain, ⁷Centro de Cirugías Especiales, Bahía Blanca, Argentina, ⁸The Whittington Health NHS Trust, London, Department of Surgery, United Kingdom, ⁹Centre Hospitalier Universitaire Félix Guyon, St Denis de la Réunion, Department of Digestive Surgery, France, ¹⁰Ospedale Evangelico Betania, Naples, Obesity and Metabolic Surgery Unit, Italy, ¹¹Miguel Hernandez of Elche University, Alicante, Spain, ¹²“Federico II” University, Naples, Advanced Biomedical Sciences Department, Italy, ¹³South Tyneside and Sunderland Foundation NHS Trust, United Kingdom, ¹⁴Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain, ¹⁵“Federico II” University, Naples, Advanced Biomedical Sciences Department, Italy, ¹⁶Brigham and Women’s Hospital, Harvard Medical School, Boston, Department of Surgery, USA

Aims: Laparoscopic bariatric surgery in patients with BMI over 50 kg/m2 is a challenging task. Over the past few decades, diffusion and standardization of principal laparoscopic bariatric procedures has led to a significant reduction of perioperative complications. However, these interventions may be challenging in patients with BMI > 50 kg/m2 with higher risks. The aim of this study was to address main issues regarding perioperative management of these patients by using a worldwide survey.

Methods: An online 48-items questionnaire-based survey on perioperative management of patients with a BMI superior to 50 kg/m2 was ideated by 15 bariatric surgeons from 9 different countries. The questionnaire was emailed to all members of the International Federation of Surgery for Obesity (IFSO). Responses were collected and analyzed by the authors.

Results: 789 bariatric surgeons from 73 countries participated in the survey. Most surgeons (89.9%) believed that laparoscopic metabolic/bariatric surgery (MBS) on patients with BMI over 50 kg/m²should only be performed by expert bariatric surgeons. Half of the participants (55.3%) believed that weight loss must be encouraged before surgery and 42.6% of surgeons recommended an excess weight loss of at least 10%. However, only 3.6% of surgeons recommended the insertion of an intragastric balloon as bridge therapy before surgery. Laparoscopic sleeve gastrectomy (LSG) was considered the best choice for patients younger than 18 or older than 65 years old. LSG and one anastomosis gastric bypass were the most common procedures for individuals between 18 and 65 years. Half of the surgeons believed that a 2-stage approach should be offered to patients with BMI > 50 kg/m², with LSG being the first step. Most participants (62.5%) stated that they had not performed robotic bariatric surgery on patients with BMIs over 50 kg/m²; however, 25.1% of participants who were experienced in robotic bariatric surgery believed that robotic surgery did not decrease postoperative morbidity in these patients. Most participants (71.8%) did not recommend any postoperative imaging while 15.5% do believe that imaging should be performed routinely before hospital discharge. 78.7% of participants recommended postoperative intensive care unit admission for selected cases. Postoperative thromboprophylaxis was recommended for 2 and 4 weeks by 37.8% and 37.7% of participants, respectively.

Conclusions: This survey demonstrated worldwide variations, common grounds and differences in laparoscopic MBS practice regarding patients with a BMI superior to 50 kg/m². Careful analysis of these results is useful for identifying several areas for future research and consensus building.

BARIATRICS—Laparoscopic

O085—Use of a Vacuum Mattress During LSG Reduces the Concentration of Rhabdomyolysis Markers But Not the Incidence of Acute Renal Failure—Prospective Clinical Trial

Mateusz Wierdak ¹, P. Małczak¹, H. Rodak¹, I. Lastovetskyi¹, A. Lasek¹, T. Wikar¹, M. Pędziwiatr¹, P. Major¹

¹Jagiellonian University Medical College, 2'nd Department of General Surgery, Poland

Aims: The aim of this prospective clinical trial is to assess the usefulness of usage of vacuum mattress during laparoscopic sleeve gastrectomy (LSG) in reduction of concentration of rhabdomyolysis markers and incidence of acute renal failure in postoperative period.

Methods: The study included 640 consecutive patients undergoing LSG surgery due to morbid obesity. Patients were divided into two groups. The first group (study group) were patients who laid on vacuum mattress during the surgery. The control group consisted of patients for whom a standard operating mattress was used during the surgery. Patients with preoperatively diagnosed chronic kidney disease were excluded from the study. The primary endpoint was the incidence of postoperative acute renal failure, the secondary endpoint was concentration of rhabdomyolysis markers (myoglobin, creatine kinase, creatinine) in first postoperative day. Perioperative care in all patients was carried out on the basis of a fully implemented ERAS protocol—> 85% of protocol elements implementation.

Results: A total of 394 patients in control group and 246 patients in study group were enrolled. The groups did not differ in terms of demographic factors, comorbidities, preoperative body weight and BMI, surgical time, incidence of intraoperative complications and intraoperative blood loss. There were no differences in incidence of postoperative kidney failure between groups (16 (4.05%) in control group, and 8 (3.25%) in study group; p = 0.218). Mean myoglobin as well as creatine kinase concentrations were significantly higher in control group (myoglobin: 143.8 ± 45.0 ng/ml—control group; 106.5 ± 38.3 ng/ml—study group; p = 0.041; kreatine kinase: 426.7 ± 182.88 U/l—control group; 233.1 ± 103.3 U/l—study group; p = 0.018) There was no difference in creatinine concentration between groups.

Conclusion: Use of vacuum mattress during LSG significantly decrease concentrations of rhabdomyolysis markers (myoglobin and creatine kinase), this however not lead to reduction of postoperative acute renal failure incidence.

BARIATRICS—Laparoscopic

O086—Comparison of Sleeve Gastrectomy with Transit Bipartition and Single Anastomosis Sleeve Ileal Bypass for Type-2 Diabetic Morbidly Obese Patients

V. Ilyashenko¹, Volodymyr Grubnik ¹, V. Grubnik¹, V. Grubnyk¹, V. Medvedev¹, S. Parfentiev¹, O. Vorotyntseva

¹Odesa Medical National University, Surgery, Ukraine

Aim: To compare the effectiveness of sleeve gastrectomy (SG) + transit bipartition (TB) and novel metabolic procedure, sleeve gastrectomy with single anastomosis sleeve ileal bypass (SASI) for treatment type-2 diabetic morbid obese patients.

Method: We have conducted a retrospective cohort study among morbid obese patients with type-2 diabetes (T2DM) who were under went a bariatric surgical procedures SG + TB and SASI between the period September 2013 and December 2020 in our hospital. The total of forty-nine patients underwent metabolic surgery for T2DM were divided into two groups. In the first group we performed SG + TB and in the second group SASI operation.The mean age of the patients was 42.6 years (26 to 64 years), mean preoperative weight was 107.5 kg (92-189.5 kg), mean preoperative BMI was 43.2 kg/m2 (36.7-65 kg/m2), and the mean excess weight was 50.8 kg (28-106 kg). Patients had a metabolic disease 7.5 years before the operation (3-21 years). Mean preoperative glycaemia was 11.8 mmol/l (6.5 to 23 mmol/l) and mean glycated hemoglobin (HbA1c) was 7.6% (6.5-13.2%).

Result: The Follow-up in 49 patients ranged from 12 to 48 months. After SG + TB operation excess weight loss was 72% at 6 months, 88% at first year, 92% at two years, 86% at four years. After SASI operation excess weight loss was 76% at 6 months, 89% at first year, 93% at two years and 82% at four years. All patients had complete resolution of diabetes in the first 6 months postoperatively. Mean postoperative levels of glycemic and HbA1c normalized from the first postoperative year. Disease was considered under control when normal levels of HbA1c (< 6%) were achieved. Insulin-depended patients achieved this control in 79% of the cases with follow-up from 12 to 48 months.

Conclusion: The novel procedure—single anastomosis sleeve ileal bypass—appears to be effective and sparing surgical treatment for morbid obesity and T2DM.

It is expedient to conduct further investigations of efficacy of this method and to define indications and contradictions for SASI.

BARIATRICS—Physiology

O087—Laparoscopic Sleeve Gastrectomy for the Treatment of Idiopathic Intracranial Hypertension in Patients with Severe Obesity

Panagiotis Lainas ¹, T. El Soueidy¹, I.B. Amor², R. Courie³, G. Perlemuter³, J. Gugenheim², I. Dagher¹

¹Antoine-Béclère Hospital, AP-HP, Paris-Saclay University, Department of Minimally Invasive Digestive Surgery, France, ²Archet II Hospital, Nice, Department of Digestive Surgery, France, ³Antoine-Béclère Hospital, AP-HP, Clamart, Paris, Department of Hepatogastroenterology, France

Aims: Severe obesity is a major risk factor for idiopathic intracranial hypertension (IIH). Data on the role of bariatric surgery for the treatment of this condition are scarce. The aim of this study was to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) on treating IIH in severely obese patients in two university bariatric surgery centers.

Methods: Prospectively collected data from consecutive patients undergoing LSG were retrospectively analyzed. Patients with IIH and referred by neuro-ophthalmologists for bariatric surgery were included in the analysis.

Results: Fifteen female patients with IIH underwent LSG (median age: 31 years). Median preoperative body mass index was 42.1 kg/m². Preoperatively, 14 patients (93.3%) had chronic headaches, 8 (53.3%) pulsatile tinnitus, and 1 (6.6%) epistaxis episodes. Ophthalmologic assessment showed bilateral papilledema in all patients, of whom 13 had visual symptoms. Median initial cerebrospinal fluid opening pressure was 31 cmH2O (range: 25-50 cmH2O); 4 patients required repeated decompressing lumbar punctures (one ventriculoperitoneal shunt). LSG was successfully performed in all patients. No patients were lost to follow-up. Mean excess weight loss was and 87.4% and 88.1% one and two years after LSG, respectively. Headaches totally resolved in 13 patients (93.3%) and improved in one (p < 0.001). Pulsatile tinnitus (p = 0.013), epistaxis, visual symptoms (p < 0.001) and papilledema (p < 0.001) significantly resolved. Medication was stopped in 14 patients (93.3%). Two years after LSG, IIH outcomes for 7 patients reaching this time-point remained unchanged.

Conclusion: This study suggests that LSG is effective for severely obese patients with IIH, resulting in complete remission or significant improvement of their symptoms as well as medication discontinuation.

UPPER GI—Benign Esophageal Disorders

O088—Redo Trans-Oral Endoscopic Stapled Diverticulostomy for Recurrent Zenker’s Diverticulum

Lavinia Barbieri¹, F. Puccetti¹, L. Cinelli¹, A. Cossu¹, E. Treppiedi¹, U. Elmore¹, R Rosati¹

¹IRCCS San Raffaele Hospital, Gastrointestinal Surgery, Italy

Introduction: Standard surgical procedure in the management of Zenker’s diverticulum (ZD) is the myotomy of the cricopharyngeal muscle combined with different treatment of the diverticulum through a left neck incision. An alternative minimally invasive approach is the trans-oral endoscopic stapled diverticulostomy (ESD), achieved with a linear stapler through a rigid endoscope, which has obtained very good results with decreased morbidity, hospitalization and operative time, early feeding and relief of symptoms. Regardless the technique, recurrence rate is not rare and reported up to 18% of patients.

To improve results of transoral stapler-assisted septotomy, we have introduced two modifications of the technique: two stay sutures (Medtronic Endostitch 10 mm suturing device) are positioned on each side of the septum, to maximise exposition and obtain traction, allowing the insertion of the stapler deeper onto the diverticular pouch and a modification of the anvil by cutting the edge of the jaw introduced in the diverticular sac.

Methods: Observational retrospective study which aim is to define feasibility and results of ESD of recurrent Zenker’s diverticulum with modificated technique. Descriptive statistics has been used with median and simple mean.

Results: A total of 28 revision surgery where included in the study: 21 patients were treated for recurrent ZD, 7 for a second recurrence. 82% (n = 23) had an ESD for a primary and second treatment, 18% (n = 5) had been previously treated with a diverticulectomy with cricopharyngeal myotomy. Revision surgery was performed via an endoscopic approach in 75% of cases (n = 21) and via an open approach in 25% of cases (n = 7), with 2 of them (7%) due to a conversion for inability of diverticuloscope insertion. Intraoperative complication occurred 1 patient in the open group with perforation of the diverticular pouch due to prior adhesions. No major complications occurred after ESD; one Clavien-Dindo IIIb complication had been reported in the open group for a haematoma requiring revision; another patient complained about dysphonia (CD II). Postoperative stay was 7 days (3-8) in the open group Vs 2 (1-4) in the ESD. Median follow up is 44 months (2-180). All patients except two, who had a redo surgery for a recurrence, referred improvement of symptoms, with only one referring mild dysphagia.

Conclusion: A modified technique of trans-oral endoscopic stapled diverticulostomy is the treatment of choice for recurrent ZD for good results and fewer complications and postoperative stay.

UPPER GI—Benign Esophageal Disorders

O089—Esophageal and Esophagocardial Junction-Related Transmural Defects—The Indication and Efficacy of Endoluminal Drainage

Martin Stašek ¹ , R. Aujeský¹, D. Klos¹, P. Ochmanová¹

¹University Hospital Olomouc, Department of Surgery, Czech Republic

Background: The therapy of esophageal and esophagocardial junction-related transmural defects requires a combined endoscopic and/or surgical approach. Endoscopic means of therapy include in general stenting, clipping, endoscopic vacuum-assisted closure and the application of tissue sealants. Surgical therapy may require drainage (surgical or CT-guided) and in the case of most severe cases resection and esophageal diversion. Endoscopic intraluminal drainage is a relatively rarely used modality.

Aim: The evaluation of endoscopic intraluminal drainage regarding the indication and technical considerations in 3 years.

Materials and Methods: Single centre study of consecutive cases of transmural esophageal and esophagocardial junction defects in 2019-2021.

Results: The study included 22 patients with postoperative and spontaneous transmural defects. 5 patients (2 × esophagocardial junction defect following sleeve gastrectomy, 1 spontaneous esophageal rupture, 1 rupture following dilatation of esophageal stricture and 1 postesophagectomy leak) were treated with endoscopic drainage. Esophagopleural drainage using double pigtail pancreatic drain 7 charr. 10 cm was successful in both cases as definitive means of therapy (long defect, 3 months of use), in one case following endoscopic vacuum-assisted closure. Transluminal intraperitoneal drainage succeeds in all cases as short term therapy (2 × 7 charr. 10 cm, 1 × 7 charr. 5 cm, SEMS failure in all cases, EVAC effective with worse compliance in 2 cases). In two cases of post sleeve gastrectomy leaks (both following the therapy of EGJ-colic fistula, polymicrobial flora), a perifocal leak recurrence leads to re-drainage (7 char. 5 cm) and conversion to transluminal external drainage with subsequent stabilisation, respectively.

Conclusion: Esophagopleural fistula with a long course is a highly potential technique for endoluminal drainage. EGJ-peritoneal drainage requires usually combined therapy including SEMS and endoscopic vacuum-assisted closure, internal drainage is an effective procedure for active perifocal collections. The recurrence of leak persistence may lead to conversion to transluminal drainage with active suction (open-pore film drainage), transluminal external drainage and/or surgical therapy. The therapeutic strategy requires further evaluation.

UPPER GI—Benign Esophageal Disorders

O090—Clinical Case: V.A.T.S. Esophageal Neoplasia Resection with Simultaneous Upper Lung Segmental Resection, Performed by “Endoscopic Rendezvous” Principle

Nikita Pepenin ¹ , Y. N. Kondratskiy², K. O. Zadorozhna¹

¹MC Dobrobut, Oncological, Ukraine, ²National Cancer Institute, Tumors of Esophagus and Stomach, Ukraine

Introduction: Although esophageal benign neoplasms are rare, leiomyoma is the most common benign submucosal mesenchymal tumor (SMT) of the esophagus, that originates from the cells of the smooth muscular layer, and form near the two-thirds (60–70%) of all benign tumors of the esophagus.

Aim. The main goal of this study is to describe the clinical case of left-sided video-assisted thoracoscopic surgery (V.A.T.S.) of esophageal neoplasia resection with simultaneous upper lung segmental resection, performed by “Endoscopic rendezvous” principle.

Materials and Methods: A 61-year-old female was admitted to our hospital with dyspepsia and food-related retrosternal pain. Endoscopic ultrasound has revealed the soft-elastic submucosal lesion, located at 22-25 cm from the incisors, up to 35 mm length, coming from the muscular layer, adjacent to the aorta and trachea. Computer tomography has shown the mediastinal lesion, most likely coming from the esophagus and the S1/S2 left lung node. No growth over the organ borders neighboring structures invasion was detected. There were no enlarged lymph nodes, and there was no evidence for distant disease spread. The size and the location of the tumor to the adjacent anatomical structures has determined the appropriate surgical approach. The left-sided V.A.T.S. esophageal neoplasm enucleation and left upper lung segment resection was suggested and performed for the purpose of morphological verification and treatment. Intraoperative endoscopy was involved for the precise tumor location identification. The extra-mucosal excision of the outer esophageal muscle was performed longitudinally and carefully dissected to separate and remove the lesion from the underlying mucosa. Preference was not given to suturing the esophageal wall defect. The pulmonary segmentectomy was completed by dint of linear stapler.

Results: The operation time was 100 min long and the hospital stay was one day. The postoperative histopathology of the specimens revealed the esophageal leiomyoma and the pulmonary hamartoma.

Conclusion: The diagnosis of esophageal leiomyoma is mostly not clear preoperatively. It may present as a mediastinal mass on chest radiograph and may be seen as an incidental radiologic finding. In the last decade, thoracoscopic minimally invasive approach has resulted in a shorter postoperative stay, reduced pulmonary complications and decreased wound pain when compared with the open procedure.

ROBOTICS & NEW TECHNIQUES—Technology

O092—PRedictive Nomogram for Anastomotic Leak and Implementation of Intraoperative Procedures to Prevent It (PRAI study): A Novel Technique to Evaluate Anastomotic Vasculariza

Monica Ortenzi ¹, A Carsetti², M Palmieri¹, E Casarotta², A Donati², M Guerrieri¹

¹Università Politecnica delle Marche, Clinica Chirurgica, Italy, ²Università Politecnica delle Marche, Clinica di Anestesia e Rianimazione, Italy

Introduction: Although altered microcirculation is defined as an independent risk factor for anastomotic leak few studies evaluated its impact on anastomotic leak and using different devices, although, none has become widely accepted. This report shows our initial experience measuring gut microcirculatory density and flow with the aid of incidence dark-field (IDF) videomicroscopy (Cytocam, Braedius, Amsterdam, The Netherlands) comparing their operative outcomes using a propensity score matching (PSM) model based on age, gender and Charlson Comorbidity Index (CCI).

Materials and methods: Videos from 5 different sites (at least 10 s/site) were recorded from both the mucosal and serosal site of the left colon end once the colonic resection was performed. At both time points with adequate focus and contrast and every effort was made to avoid movement and pressure artefacts. Poor-quality images were discarded and 3 images for each time point were selected and analyzed using a computer software package (Automated Vascular Analysis Sofware, Microvision Medical BV, Amsterdam, The Netherlands). According to the consensus report on the performance and evaluation of microcirculation using IDF imaging, total vessel density (TVD) and perfused vessel density (PVD) were calculated for small vessels (diameter < 20 μm). The De Backer score was calculated as described previously. The proportion of perfused vessels (PPV) and the microvascular flow index (MFI), reflecting microcirculatory blood flow velocity, were analyzed semi-quantitatively in small vessels, as de- scribed elsewhere. The flow heterogeneity index (HI) was also calculated as the highest MFI minus the lowest MFI divided by the mean MFI, providing an index of heterogeneous microcirculatory perfusion. At each recording noninvasive measurement of blood pressure, heart rate, temperature, use of vasoactive drugs and peripheral oxygen saturation (measured with a probe on a digit or ear) were simultaneously recorded. The association between post-operative outcomes and microcirculation evaluation were investigated using propensity score matching and multivariable logistic regression models.

Results: Nineteen patients were considered eligible for the study (males = 8, 42.1%; mean age = 61.2), all of them underwent laparoscopic rectal anterior resection. The mean TVD 8.85 (95%CI = 7.33-10.36), PPV was 100 in all patients but 2, while the mean MFI was 2.79 (95%CI = 2.33-3.23). The mean PVD was 8.63 (95%CI = 5.75-11.52) while the mean De Becker score was 4.51 (95%CI = 3.73- 5.28). In 1 patient (5.3%) the finding of altered vascularization resulted in the change of the operative strategy with an extension of the resection point. In this patient the PVD was 2.78, and De Becker score was 7.69. No intraoperative complications were recorded. One patient experienced major bleeding in the post-operative period that was managed with a second laparoscopy. No anastomotic leak was observed. Anastomotic leak occurred in 2 patients in (p = 0.811). The evaluation of microvascularization was not associated with post-operative complications in unmatched (OR = 1.15, 95% CI = 0.734-13.705) nor in matched patients (OR = 6.538, 95%CI = 0.678-62.989)

Conclusions: Though the results are preliminary this type of anastomotic evaluation showed to be feasible, safe and useful to easily detect any alteration of the resected colon before anastomotic construction. Moreover, in times when the constant increasing awareness for costs of the healthcare system could pose a limit to the spread of new technologies this type of anastomotic evaluation offers a in a more cost-effective manner than other devices.

ROBOTICS & NEW TECHNIQUES—Solid Organs

O093—Operating Time Significantly Decreases After Learning Curve—Lessons Learned After > 150 Robotic Assisted Minimally Invasive Esophagectomies (RAMIE)

Dolores Müller ¹, B. Babic¹, J. Eckhoff², L. Schiffmann¹, W. Schröder¹, C. Bruns¹, H. Fuchs¹

¹University of Cologne, Department for General, Visceral, Cancer and Transplant Surgery, Germany, ²Massachusetts General Hospital, Surgical AI & Innovation Laboratory, Department of Surgery, USA

Introduction/Aim: The use of robotic technology in general surgery is rapidly increasing in Europe. While this has reduced the invasiveness of procedures resulting in improved patient outcomes, many claim that the use of new technology, such as a robotic device, increases the duration of surgery especially in complex cases. The aim of this study is to evaluate and share our experience as a center of excellence for surgery of the upper gastrointestinal tract for robotic assisted minimally invasive transthoracic esophagectomy (RAMIE) with a focus on duration of surgery.

Methods: Analysis of our prospectively collected, IRB approved database of robotic esophagectomies was performed. Starting 01/2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for our RAMIE cases at our academic center. Duration of surgery was defined as incision-suture time in minutes. In addition, an analysis of operating time of the abdominal (gastrolysis including repositioning of the patient) and thoracic (esophagectomy, reconstruction, defined as time of single lung ventilation) parts of the procedure is shown separately. Operation times from the first introduction of the technique in 2017/2018 at our clinic are compared to a standardized and now experienced approach from the same surgeons in 2021.

Results: Sine 2017 a total of 156 patients underwent a robotic assisted Ivor Lewis esophagectomy at our clinic. Of these, a total of 145 were included in the analysis. Eleven patients were excluded from the analysis as concomitant surgery was performed or a two-stage approach was chosen. Mean operating time was 385.7 min in the overall cohort (range 235–640 min). Mean operating times and comparison of groups are shown in Table 1. As expected, operating times significantly decreased over time, especially for the thoracic part of the surgery. Figure 1 shows the decreasing trend over several years.

Conclusion: Duration of robotic assisted minimally invasive esophagectomy significantly decreases after completion of the learning curve. This effect is especially seen for the thoracic part of the procedure with reconstruction using a gastric conduit and performing an esophagogastric anastomosis.

SOLID ORGANS—Adrenal

O094—Laparoscopic Transperitoneal Adrenalectomy v.s. Posterior Retroperitoneal Adrenalectomy in the Aspect of Cardiovascular System Function

Marta Lewoc ¹ , B. Choromańska¹, T. Kozłowski¹, P. Myśliwiec¹, J. Dadan¹

¹Medical University of Białystok, 1st Department of General and Endocrine Surgery, Poland

Introduction: Laparoscopic adrenalectomy has become the gold standard in management of benign adrenal tumors and isolated metastases. Two alternative techniques of endoscopic approaches are performed routinely—lateral transperitoneal adrenalectomy (LTA) and posterior retroperitoneal adrenalectomy (PRA). Mean insufflation pressure is on average twice higher in PRA than in LTA.

Aim: The aim of our study was to prospectively assess the effect of LTA versus PRA laparoscopic adrenalectomies on cardiovascular system function.

Materials and Methods: The patients referred for unilateral adrenalectomy were randomly assigned to either LTA (n = 33) or PRA (n = 44). We measured cardiac output, brain natriuretic peptide (BNP) and high sensitivity troponin I (hsTnI) a day before the surgery, and a day, a week, and a month after the surgery. The inclusion criteria were: the tumour diameter > 4 cm and < 8 cm in CT and/or hormonal activity and/or suspicion of metastasis to adrenal gland. Patients with primary neoplasms were excluded from the study.

Results: 77 videoscopic adrenalectomies were performed, 33 (42,9%)—LTA, 44 (57,1%)—PRA. The average tumour size in LTA—4 cm, in PRA—4.1 cm. Based on histopathological findings, most commonly removed tumours were adrenal gland adenomas: LTA—82%, PRA—70%. There were no complications registered in the studied group intra nor postoperatively. We found no significant differences in the levels of BNP, hsTnI and indirect cardiac output measurements between LTA and PRA groups. However, the rate of decrease in BNP concentrations between day 1 and day 7 postoperatively, was greater in the group of patients undergoing LTA than PRA (p < 0,0001).

Conclusions: Both LTA and PRA were safe. Whether patients with high risk of cardiovascular incidents might benefit from LTA as compared to PRA, requires further research.

SOLID ORGANS—Adrenal

O095—Long Term Follow Up of Patients Undergoing Laparoscopic Surgery for Pheochromocytoma and Paraganglioma

P. O'Dwyer¹, Samer Zino ², C. Chew³, M. Serpell⁴

¹Ninewells Hospital and Medical School, General Surgery, United Kingdom, ²University of Glasgow College of Medical Veterinary and Life Sciences, Radiology, United Kingdom, ³Gartnavel General Hospital, Department of Anaesthesia, United Kingdom, ⁴Ninewells Hospital and Medical school, General Surgery, United Kingdom

Phaeochromocytomas are rare tumours with a recurrence following open operation ranging between 6-23%. Long term follow-up studies following laparoscopic surgery for phaeochromocytoma are lacking. The aim of this study was to evaluate the long-term outcome of a consecutive cases of patients with pheochromocytoma who were surgically treated in the same centre.

Materials and Methods: Prospectively collected date for patients with adrenal tumour or paraganglioma were collected in the study period between September 1999 and December 2017. Each case had final review and follow up assessment on November 2021.

Results: 472 patients underwent 504 (32 bilateral lesions) operations for adrenal or paraganglioma. 135 patients (28.6%) of these cases were phaeochromocytoma out of which (118) 87% were attempted laparoscopically, 5 cases out of the 118 were convert to open (4.2.%). Patient age ranged between 15 and 82y. tumours size ranged between 5 and 150 mm. 117 cases had curative surgery. There was no peri operative or post-operative mortality. No patient had a local recurrence. Disease free survival was 96% at 5 years and 92% at 10 years. At a median follow-up of 10 years (interquartile range 6-12.85 years), only 3 (2.56%) patients died from metastatic phaeochromocytoma at 5, 5.5 and 6.2 year. A further patient developed lymph node metastases that were removed using open approach. The only significant predictor of recurrence was the presence of lymph node metastases (p < 0.0001).

Conclusions: This study demonstrates that laparoscopic surgery may have an oncologic as well as clinical advantage over the open approach for phaeochromocytoma with 92% disease free survival at 10 years. Laparoscopic adrenalectomy should be considered the procedure of choice for pheochromocytoma.

SOLID ORGANS—Adrenal

O096—Is Laparoscopic Adrenalectomy for Pheochromocytoma Really More Challenging? A propensity score-matched analysis

Diletta Corallino ¹, A Balla¹, M Ortenzi², L Palmieri¹, F Meoli¹, M Guerrieri², A.M Paganini¹

¹Sapienza University, Policlinico Umberto I, Rome. Italy, Department of General Surgery and Surgical Specialties “Paride Stefanini”, Italy, ²Università Politecnica delle Marche, Ancona, Italy, Department of General Surgery, Italy

Aims: Laparoscopic adrenalectomy (LA) is the gold standard for the treatment of adrenal masses, but its role in case of pheochromocytoma is still debated. The aim of the present study is to report the results of LA in case of pheochromocytoma in comparison to other types of lesions.

Methods: From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients were excluded due to bilateral and open adrenalectomy, respectively. 572 patients were included in the present study: 114 and 458 patients underwent LA for pheochromocytoma (Group A) and other types of lesions (Group B), respectively. To adjust for potential baseline confounders, propensity score matching (PSM) was conducted at a 1:1 ratio. Surgical and perioperative outcomes were compared between the two groups.

Results: After PSM, 114 matched pairs of patients (with no differences in patient demographics or tumor characteristics) were identified from each group. No statistically significant differences were observed between the two groups comparing median operative time: 83.8 min in Group A, 88.2 min in Group B (p = 0.627); conversion rate: six complications observed in both groups (p = 1.000); transfusion rate: four in Group A and three in Group B (p = 1.000); complication rate: seven in Group A and nine in Group B (p = 0.796); median postoperative hospital stay: 3.9 days in Group A, 3.6 days in Group B (p = 0.110); mortality rate: one death observed in each group (p = 1.000).

Conclusions: Based on this study, the results of LA for pheochromocytoma are equivalent to those of LA for other types of tumor, as long as it is performed by experienced surgeons with a multidisciplinary patient management. Further prospective studies with a larger number of patients are required to draw definitive conclusions.

SOLID ORGANS—Adrenal

O097—Plasma and Urinary Antioxidant and Antiradical Activity Depend on Adrenal Tumor Type

Kamil Astapczyk ¹, B. Choromańska², P. Myśliwiec², T. Kozłowski², J. Łukaszewicz², H. Vasilyevich³, J. Dadan², A. Zalewska⁴, M. Maciejczyk⁵

¹1st Department of General and Endocrine Surgery, Medical University of Bialystok, Poland, ²Medical University of Bialystok, 1st Department of General and Endocrine Surgery, Poland, ³Grodno State Medical University, Department of General Surgery, Belarus, ⁴Medical University of Bialystok, Experimental Dentistry Laboratory, Poland, ⁵Medical University of Bialystok, Department of Hygiene, Epidemiology and Ergonomics, Poland

Redox imbalance may be involved in cancer development and progression. In this study we focused on evaluating the total antioxidant capacity (TAC) in patients with adrenal tumors. This parameter assesses redox status of biological system more accurately than separate antioxidants. This study is the first to describe this criterion. The study group consisted of 60 patients (31 women and 29 men) with adrenal masses, classified into three subgroups: non-functional incidentaloma, pheochromocytoma and Cushing’s/Conn’s adenoma. The number of patients was set a priori based on our previous experiment (α = 0.05, test power = 0.9). The control group comprised 60 matched healthy subjects. Ferric reducing antioxidant potential (FRAP) was decreased in plasma and urine, while DPPH (2,2-diphenyl-1-picrylhydrazyl) antiradical activity only in plasma of patients with adrenal masses as compared to control group. TAC was increased in patients with incidentaloma, while it was decreased in pheochromocytoma patients. Plasma and urine total oxidant status (TOS) and oxidative stress index (OSI) were significantly higher in patients with adrenal tumors than in healthy subjects. In conclusion, we demonstrated reduced radical scavenging capacity in the plasma/urine of the patients with hormonally active adrenal masses. Plasma TAC was significantly higher in the incidentaloma group compared to controls. Thus, plasma and urinary antioxidant and antiradical activities depend on adrenal tumor type. Lower levels of TAC, DPPH and FRAP clearly indicate reduced ability to scavenge free radicals and, hence, the lack of effective protection against oxidative stress in patients with adrenal tumors. Both plasma and urine redox biomarkers can be used to assess systemic antioxidant status in adrenal tumor patients.

SOLID ORGANS—Adrenal

O098—Comparison of Effectiveness and Complications of Laparoscopic Transabdominal and Retroperitoneoscopic Adrenalectomy

Volodymyr Grubnik ¹, R. S. Parfentiev¹, V. V. Grubnyk¹, O. S. Burlak¹, V. V. Ilyashenko¹

¹Odessa National Medical University, Surgery, Ukraine

Laparoscopic adrenalectomy is the “gold standard” approach for benign adrenal framers. Majority of surgeons perform laparoscopic transabdominal adrenalectomies. Retroperitoneoscopic adrenalectomies in prone position by Waltz have some advantages for patients. Aim of the study was to compare effectiveness and number of complications of two Methods: transabdominal and retroperitoneoscopic laparoscopic adrenalectomies.

Material and Methods: From 2000 to 2020 years 468 laparoscopic adrenalectomies were performed in our clinic. Age of the patients from 19 to 79 years, mean age 50,5 ± 10,2 years. There were 312 women, and 156 men. Indication for operation were follows: incidentaloma—32,5%, pheochromocytoma—30,2%, aldosteronoma—19%, corticectomy -10,3%, myelolipoma—3%, metastatic cancer—5%. Size of tumors was from 1 to 10 cm.

Results: Transabdominal adrenalectomies were performed in 312 patients: right adrenal ecotones—204 patients, left adrenalectomies—108 patients. Size of tumors were: 1-2 cm—106 patients, 3-4 cm—98 patients, 4-6 cm—81and more than 6 cm in 27 patients. Complication’s rate was 8,9% (28 patients), conversions were in 8 patients (2,6%). Retroperitoneoscopic adrenalectomies were performed in 156 patients. Size of tumors were: 1-2 cm in 96 patients. 3-4 cm—39 patients, 4-6 cm—18 patients, more than 6 cm in 3 patients. Complication rate was 12,2% (19 patients). Conversions to transabdominal approach was in 3 patients with tumor size more than 6 cm and in 4 patients with size of tumor 4-6 cm, conversions rate was 4,9%. In the patients with small tumors retroperitoneoscopic approach has some advantages: shorter curation of surgery, lower operative blood loss, diminished pain intensity, lower prevalence of shoulder—tip pain, shorter time to oral intake, shorter length of hospital stays.

Conclusions: Both approaches were equally safe. In the patients with small tumors retroperitoneoscopic adrenalectomies were superior to transabdominal approach in terms of shorter surgery duration, lower blood loss, lower postoperative pain, faster recovery, good cosmetic.

Results: In the patients with large tumors transabdominal approach is much better with lower complications and conversions rate.

SOLID ORGANS—Adrenal

O099—Association of Tumor Size with Protein Glycooxidation and Carbamylation in Patients with Adrenal Masses

Konrad Wiśniewski ¹, P. Myśliwiec¹, B. Choromańska¹, M. Luba¹, P. Wojskowicz¹, J. Dadan¹, A. Zalewska², M. Maciejczyk³

¹Medical University of Białystok, 1st Department of General and Endocrine Surgery at the University Hospital in Bialystok, Poland, ²Medical University of Białystok, Experimental Dentistry Laboratory, Poland, ³Medical University of Białystok, Department of Hygiene, Epidemiology and Ergonomics, Poland

Adrenocortical carcinoma is very aggressive tumor. The risk of malignancy of adrenal masses is associated with size of the tumor. It is argued that the size of adrenal tumors is the best predictor of malignancy. Ranging in size from 4.1 cm to 6 cm may become malignant in 6% of cases. Whereas tumors larger than 6 cm may be malignant even in 25% of cases. It would be helpful to find a marker correlating with adrenal tumor size, enabling an early diagnosis. Oxidative stress is involved in the carcinogenesis. Reactive oxygen (ROS) and nitrogen (RNS) species induce oxidation of proteins, leading to disturbances in their structure and function. Also, carbamylation process caused a post-translational modification of proteins. Therefore, the aim of our study was evaluation of protein glycooxidation and carbamylation in 53 patients (24 women and 29 men aged from 47 to 63 years) with adrenal masses (AM) depending on tumor size. Patients were undergoing elective endoscopic adrenalectomy (lateral transperitoneal approach or posterior retroperitoneal approach) at the 1st Department of General and Endocrine Surgery at the University Hospital in Bialystok, Poland. The control group consisted of 30 healthy volunteers (14 women and 16 men aged 48 to 63) who visited the Specialist Dental Clinic at the Medical University of Bialystok for routine checkup. All blood samples were collected in a fasting state into EDTA tubes. The plasma content of AGE (advanced glycation end products) was determined spectrofluorimetrically and carbamyl-lysine (CBL) was assayed colorimetrically. We found significantly higher plasma content of AGE and CBL in patients with adrenal masses: AM < 4 cm and AM > 4 cm in comparison with the controls. Additionally, plasma content of CBL was higher in patients with AM > 4 cm than the patients with AM < 4 cm. In conclusion, we showed that protein glycoxidation and carbamylations are intensified in patients with adrenal tumors, however glycoxidation not dependent on tumor size. Plasma content of CBL may be a potential marker of tumor size in patients with adrenal masses.

SOLID ORGANS—Adrenal

O100—Laparoscopic Transabdominal Bilateral Anterior Adrenalectomy (La-TABA): An Alternative Approach for Severe Cushing’s Syndrome

Francesco Pennestrì ¹, C. De Crea², L. Sessa¹, P. Gallucci¹, P.F. Procopio², F. Prioli¹, P. Princi¹, L. Revelli², M.P. Cerviere¹, R. Bellantone², M. Raffaelli²

¹Fondazione Policlinico Universitario Agostino Gemelli IRCCS, U.O.C. Chirurgia Endocrina e Metabolica, Italy, ²Fondazione Policlinico Universitario Agostino Gemelli IRCCS—Università Cattolica del Sacro Cuore, U.O.C. Chirurgia Endocrina e Metabolica, Italy

Aims: Severe uncontrolled Cushing’s syndrome (CS) is an acute life-threatening condition. As it is often not responsive to medical therapy, emergency bilateral adrenalectomy (BA) may represent the only therapeutic option. Moreover, the clinical consequences of hypercortisolism, such as multiple bone fractures, may not permit both prone and lateral patient’s positioning during surgery, making minimally-invasive procedures not feasible. Therefore, in this scenario conventional surgery may result to be mandatory, though the post-operative complications tend to worsen the already compromised clinical conditions of these patients. We report our preliminary experience with an alternative approach in this selected category of patients.

Method: Among 613 patients who underwent endoscopic adrenalectomy at our Center (34–5.6% BA) between January 1997 and October 2021, 3 patients were scheduled for Laparoscopic Transabdominal Anterior Bilateral Adrenalectomy (La-TABA). Surgery was performed with patient in supine position, with fastened arms and legs in order to allow Trendelenburg and anti-Trendelenburg movements and lateral rotations. The procedure was a synchronous bilateral adrenalectomy and the surgical steps were the same as the lateral transabdominal approach, with 7 trocars (four in right subcostal position and three in left subcostal position). A modern operative table provided rotations on right and left side in order to perform left and right adrenalectomy respectively: actually it simulates the lateral position, letting gravity expose adrenal lodges during dissection.

Results: 1 male and 2 female patients with mean age 34 ± 3.1 years underwent La-TABA for non-responsive to medical therapy, neurosurgical and gamma-knife treatments-CS in 2 cases and for ectopic ACTH-secretion due to metastatic medullary thyroid carcinoma in the other case. Mean operative time was 200 ± 138.3 min. No intraoperative and 30-days postoperative complications were registered. Mean postoperative hospital stay was 8 ± 4.4 days, necessary for the management of hypercortisolism.

Conclusions: In very severe ACTH-dependant CS BA should be performed as soon as possible. In this scenario La-TABA may represent the best therapeutic option, as this patients category is not able to tolerate prone and lateral positioning during surgery. Despite the higher technical complexity of the procedure compared with the other endoscopic approaches to adrenalectomy, it allows to achieve similar advantages in terms of post-operative complications and recovery.

UPPER GI—Reflux-Achalasia

O101—Post myotomy Esophageal Diverticula Can Mimic Recurrence of Achalasia Symptoms but may be Treated with Diverticulectomy Only

Main author: Gad Marom: Yuri Fishman ¹, G. Marom¹, R. Elazary¹, H. Jacob², R. Brodie¹, Y. Mintz¹

¹Hadassah Ein Kerem, General surgery, Israel, ²Hadassah Ein Kerem, Department of Gastroenterology, Israel

Background: Esophageal epiphrenic diverticulum is a rare diagnosis, usually associated with esophageal motility disorder. Symptoms include dysphagia, heartburn, chest pain, and regurgitation. Esophageal Diverticulum (ED) following esophageal myotomy for achalasia may develop due to the lack of muscle wall support and negative pressure in the mediastinum. Symptomatology may be similar to or mimic exacerbation of achalasia, however in cases where the LES is open a simple diverticulectomy could alleviate symptoms.

Methods: We retrospectively reviewed a prospectively maintained database of patients who underwent myotomy in our institution between December 2012 and November 2020. A total of 136 patients underwent POEM, and a 48 underwent Laparoscopic or robotic assisted Heller Myotomy. Two patients (1.1%) developed symptomatic post myotomy ED, and another patient was treated for post myotomy ED following Laparoscopic Heller myotomy in a different institution.

Results: The time to diagnosis of ED was 180, 77, and 35 months following myotomy. Symptoms included regurgitation, dysphagia and heartburn. Endoscopic findings showed large epiphrenic esophageal diverticulum with patent gastroesophageal junction without obstruction. Two patients underwent laparoscopic diverticulectomy with intraoperative endoscopy evaluation. The third patient is scheduled for surgery. Revisional myotomy was unnecessary. Post-operative swallow studies demonstrated significant improvement of contrast agent flow to the stomach. All patients reported significant relief with a follow up of 6 months to 3 years.

Conclusion: Post myotomy ED is a very rare condition, which may develop within 35-180 months following surgery. Evaluation of symptoms, anatomy and esophageal function is needed to discriminate between insufficient myotomy and ED only. Laparoscopic diverticulectomy without additional myotomy appears to be a safe and effective treatment for this unique entity.

ROBOTICS & NEW TECHNIQUES—Technology

O102—Revisiting the Splenic Flexure Cancer, Personalised Surgery After Anatomical Considerations using 3D Printed Models and 3D Reconstructions

Bjarte Tidemann Andersen ¹, B.V. Stimec², A.M. Kazaryan¹, P. Rancinger¹, B. Edwin³, D. Ignjatovic⁴

¹Ostfold Hospital Trust, Surgical Department, Norway, ²University of Geneva, Anatomy Sector, Teaching Unit, Switzerland, ³Oslo University Hospital, Rikshospitalet, Interventional Center, Norway, ⁴Akershus University Hospital, Department of Digestive Surgery, Norway

Aims: The splenic flexure is situated in-between two vascular areas irrigated from the middle colic artery (MCA) and from the inferior mesenteric artery (IMA). The aim of this study is to explore the impact of the MCA bifurcation, the presence of the accessory middle colic artery (aMCA), the 3-dimensional relationship between the two vascular areas and the pattern of the inferior mesenteric vein (IMV) confluence.

Methods: The vascular anatomy was studied using 32 preoperative high-resolution CT scans. The CT scans were manually 3D reconstructed using Osirix MD, Mimics Medical and 3-matic Medical Datasets, and exported for further investigations as PDF files, video clips, stills and STL files for 3D printing as shown in Fig. 1.

Results: The most common position (53.1%) for the MCA bifurcation was in front of the superior mesenteric vein (SMV), followed by right to SMV (34,4%) and left to SMV (12.1%). The median distance from the MCA origin to the MCA bifurcation was 3.21 cm. The aMCA was found in 31.3% of the patients. All aMCA trajected towards the splenic flexure. 50% directly through the transverse colon mesentery, and 50% following the lower pancreatic border before turning towards the flexure. The origin of MCA could be found both cranial (87.5%) and caudal (9.4%) to the origin of IMA. 3.1% of the patients lacked proper MCA. We found an anatomical triangle between the MCA origin, the aorta, and the IMA origin. This triangle represents the mesenteric inter-arterial step. The IMV has two main confluence patterns, to the SMV, either through a jejunal vein or directly (65.6%) or to the splenic vein (34.4%). Either way, the path of the IMV could be infrapancreatic (53.1%), infrapancreatic with a retropancreatic arch (21.9%) or true retropancreatic (25%).

Conclusion: Today the surgeon could be aided by many techniques giving the possibility to personalise surgery according to patient specific anatomy. The different anatomical variants might represent different possible lymphatic pathways which must be considered. To overcome the challenges presented by the mesenteric inter-arterial step, the surgeon could follow the IMV.

COLORECTAL—Malignant

O103—Pathology Assessment of Mesorectal Fascia After TME by Laparoscopic, Open, TransAnal and Robotic Approaches (LOTARTME Trial)

Marco Maria Lirici¹, Andrea Biancucci ¹, A. Biancucci¹, A. Fassari², D. Campagna², M. Giordano², G. Pernazza³, C. Vitelli⁴, E. Santoro¹

¹San Giovanni Addolorata Hospital Complex, Department of Oncologic Surgery, Italy, ²San Giovanni Addolorata Hospital Complex, Department of Pathology, Italy, ³San Giovanni Addolorata Hospital Complex, Robotic Surgery Unit, Italy

Aim: Total Mesorectal Excision (TME) is the gold standard surgical treatment for rectal cancer. Specimen quality, integrity of mesorectal fascia and lymph nodes harvest are expression of radicality and good surgery. The study was designed to assess which of openTME, laparoscopicTME, roboticTME and transanalTME approach is superior in term of specimen quality.

Materials and Methods: Consecutive patient from January 2017 to December 2020 who underwent TME procedure for curative treatment of rectal adenocarcinoma (distal extent ≤ 15 cm of the anal margin) was collected in an observational prospective database. A single centre, non-randomized, cohort study comparing open, laparoscopic, robotic and transanal (TaTME) approach was performed. Participating surgeons had to perform at least 100 TME procedure. The target follow-up was 4 years with a minimum of 6 months. All intent-to-treat procedures were included regardless of pathological stage and radiological T extension. The primary end point was completeness of mesorectal fascia assessed using the 3-grade Quirke classification. Secondary end points were the number of harvested lymph nodes and the 1 and 3 years oncological outcomes: local recurrence rate (LR), overall survival (OS) and cancer specific survival (CSS).

Results: 154 consecutive patients were enrolled. The 4 treatment groups were well balanced based on pre-operative characteristics and surgical procedures. The quality of the mesorectal fascia was of the highest oncological standard (complete or nearly complete) in 136 of 154 cases (89%): 98% in the TaTME group, 88% in the LapTME group, 87% in the robTME group and 80% in the openTME group. There was statistically significant difference between TaTME and OpenTME group and nearly significant compared to other miniinvasive approach. The total number of lymph nodes retrieved at pathology was more high in the LapTME than in the other groups although this group contains the least number of patients exposed to neo-adjuvant radiochemotherapy. The local recurrence rate was better in TaTME group (5.5%) than in the other groups (8.1% LapTME, 8.8% RobTME and 13% OpenTME). Also all the survival rates was better in TaTME group than in the other groups: 100% in 3-years OS and CCS compared to 87% and 100%, 86% and 90%, 82% and 96% in the LapTME, RobTME, OpenTME group respectively.

Conclusions: We conclude that TaTME is able to allow higher quality of mesorectal excision than the open technique and suggests a similar result compared to the other mininvasive approaches. LR and the OS and CSS would seem to suggest better outcomes in the TaTME group compared to other techniques although not enough statistical evidence was found. Finally, lack of evidence to standardize the indications and the use of the TaTME are still present. However, the study clearly demonstrates that TaTME can be an effective alternative in rectal surgery in the hands of experienced surgeons, especially in low and ultra-low tumor localizations and in difficult anatomical conditions.

UPPER GI—Esophageal cancer

O105—Hospital Variation in Feeding Jejunostomy Techniques During Minimally Invasive Esophagectomy; Population-Based Results from the Dutch Upper gastrointestinal Cancer Audit

Maurits Visser ¹, J. Straatman², D.M. Voeten², J.P. Ruurda³, S.S. Gisbertz³, R. van Hillegersberg⁴, D.L. van der Peet⁵, M.I. van Berge Henegouwen⁴, On behalf of the Dutch Upper Gastrointestinal Cancer Audit (DUCA) Group

¹UMC Utrecht/Dutch Institute for Clinical Auditing, Gastrointestinal Surgical Oncology, The Netherlands, ²Amsterdam Universitair Medisch Centrum, Surgery, The Netherlands, ³Universitair Medisch Centrum Utrecht, Gastrointestinal Surgical Oncology, The Netherlands, ⁴Amsterdam Universitair Medisch Centrum, Upper GI Surgery, The Netherlands, ⁵Universitair Medisch Centrum Utrecht, Gastrointestinal Surgical Oncology, The Netherlands

Aims: No consensus exists on the technique and safety of feeding jejunostomy (FJ) during esophagectomy. This study aims to investigate hospital variation in placement and safety of FJ during esophagectomy in the Netherlands.

Methods: This nationwide cohort study included all patients registered in the Dutch Upper Gastrointestinal Cancer Audit undergoing minimally invasive esophagectomy from 2018-2020. Hospital variation in FJ placement techniques and usage was investigated using a survey questionnaire among all Dutch esophagectomy centers. Hospital variation in FJ placement rates was investigated using case-mix corrected funnel plots. Incidence of intra- and postoperative complications, prolonged hospital stay and reinterventions was compared between patients with and without FJ using multilevel multivariable logistic regression. Additionally, the incidence, Clavien-Dindo score and reintervention rates of FJ-related complications were described. Lastly, FJ-related complication rates were compared between hospitals performing jejunostomies routinely (≥ 90% of patients) and not routinely (< 90%).

Results: A FJ was placed in 1553/1900 (81.7%) of included patients, with rates ranging from 11 to 100% between hospitals. Gastric-tube necrosis was seen more frequently in patients without FJ versus those with FJ (2.9% vs. 0.4%; OR:0.14, 95%CI:0.05-0.39), while chyle leakage was more common in FJ patients (9.4% vs. 5.1%; OR:1.92, 95%CI:1.16-3.40). Hospital stay (~ 10 days; Dutch median) was shorter in patients with FJ compared with those without FJ (50.0% vs. 63.4%; OR:0.64, 95%CI:0.44-0.93) after FJ placement (Table 1). In total, 46/1553 (3%) patients had FJ-related complications, of whom 23 (1.5%) experienced severe complications (≥ Clavien-Dindo IIIa). The jejunostomy complication rate in hospitals routinely/not routinely placing FJ was 1.6% and 9.3% respectively (p < 0.01).

Conclusion: Hospital variation in placement of FJ exist in the Netherlands. In patients with FJ a lower gastric-tube necrosis rate was observed, but also an increased chyle leakage rate and length of hospital stay. Centers routinely performing jejunostomy have a lower jejunostomy complication rate than centers performing it selectively. Even though confounding by indication might exist, the hospital variation does show room for nationwide improvement.

ROBOTICS & NEW TECHNIQUES—Technology

O106—Importance of Clinically Adequate Labelling in Surgical Phase Detection of Laparoscopic Cholecystectomy Procedures

F. Voskens¹, Julian Abbing ¹ , N. E. van de Kar¹, J. R. Abbing¹, B. G. A. Gerats¹, I. A. M. J. Broeders¹

¹Meander Medical Center, Department of Surgery, The Netherlands

The increasing acquisition and availability of endoscopic recordings in minimally invasive surgery (MIS) have created opportunities for the integration of Computer Vision (CV) technologies in the operating theatre. Video recordings of the laparoscopic cholecystectomy have been interesting for CV research on autonomous detection and identification of specific phases in the procedure. Deep Learning (DL) models, a type of CV, generally require large amounts of annotated data. However, manual annotations of laparoscopic surgery videos tend to be difficult to create. Correct annotation is of importance as it provides the ground truth labels and consistency in this process can positively influence the learning capabilities of DL models. This work investigates the effect of annotation quality on the performance of a neural network for surgical phase recognition on the Cholec80 dataset. Therefore, we compared the performance of a ResNet-50, which was trained on two different annotation sets. First, the model was trained with the original labels of the Cholec80 dataset, which consisted of seven phases. Thereafter, the same model was trained on the Cholec80 videos with the revised annotations. The revised annotations were created on clinically relevant and visually present cut-off points, consisting of six phases including a non-surgical out-of-body phase. Analysis, after optimal training of the models, was based on frame-wise accuracy, recall, precision and F1-scores. Preliminary results show that the model trained on original annotations classified the correct phase with an overall accuracy of 79.0%, 80.5% precision, 78.1% recall and 79.3% F1-score. The model achieves a higher performance when trained with the revised annotations, showing a mean of 85.0% accuracy, 86.3% precision, 84.3% recall and 85.3% F1-score. Our proposed revised annotation dataset improved the performance of the ResNet-50 in surgical phase recognition. This supports the importance of clinically relevant and consistent annotations, to be able to get the model trained properly. Furthermore, the introduction of out-of-body segments has had a positive impact on the model's ability to identify surgical phases.

ROBOTICS & NEW TECHNIQUES—Solid organs

O108—Cost-effectiveness and Outcome of Robot-Assisted vs Laparoscopic Lateral Transabdominal Adrenalectomy: A Propensity Score Matching Analysis from an High-Volume Center

C. De Crea¹, Francesco Pennestrì ¹, F. Pennestrì², L. Sessa², P.F. Procopio¹, P. Gallucci², S. Di Lorenzo¹, G. Salvi¹, L. Ciccoritti², G. Greco², R. Bellantone¹, M. Raffaelli¹

¹Fondazione Policlinico Universitario Agostino Gemelli IRCSS—Università Cattolica del Sacro Cuore, U.O.C. Chirurgia Endocrina e Metabolica, Italy, ²Fondazione Policlinico Universitario Agostino Gemelli IRCCS, U.O.C. Chirurgia Endocrina e Metabolica, Italy

Aims: Laparoscopic adrenalectomy (LA) is the gold standard treatment for adrenal lesions. Robot-assisted adrenalectomy is a safe approach associated with higher costs in absence of clear-cut benefits. Several series reported some advantages of RAA over LA in challenging cases, but definitive conclusions are lacking. We evaluated the cost-effectiveness and the outcome of robot-assisted (RA-LTA) and laparoscopic (L-LTA) lateral transabdominal adrenalectomy in a high-volume Center.

Method: Among 356 minimally invasive adrenalectomies (January 2012—August 2021), 286 were performed with a lateral transabdominal approach: 191 L-LTA and 95 RA-LTA. The RA-LTA and L-LTA patients were matched for lesion side and size, hormone secretion and BMI with propensity score matching (PSM) analysis. Postoperative complications, operative time (OT), post-operative stay (POS), and costs were compared.

Results: PSM analysis identified 184 patients, 92 in RA-LTA and 92 in L-LTA group. The two groups were well matched. The median lesion size was 4 cm in both groups (p = 0.533). Hormonal hypersecretion was detected in 55 and 54 patients of RA-LTA and L-LTA group, respectively (p = 1). Median OT was significantly longer in RA-LTA group (90.0 Vs 65.0 min) (p < 0.001). No conversion was registered. Median POS was similar (4.0 Vs 3.0 days in the RA-LTA and L-LTA) (p = 0.467). No difference in postoperative complications was found (p = 1). The cost margin analysis showed a positive income for both procedures ((3137 Vs 3968 € for RA-LTA and L-LTA).

In the multiple logistic regression analysis, independent risk factors for postoperative complications were hypercortisolism (OR = 24,197, p = 0.028), OT > 75 min (OR = 12,441, p = 0.026), lesion size > 6 cm (OR = 24,298, p = 0.032). In subgroup analysis the median OT of RA-LTA and L-LTA was 90.0 Vs 75.0 min (p = 0.545) and 90.0 Vs 89.0 min (p = 0.620) respectively for hypercortisolism and lesion size > 6 cm.

Conclusions: The postoperative outcome of RA-LTA and L-TLA was similar in our experience. Despite the higher cost, RAA appears to be cost-effective and economically sustainable in a high-volume center (60 adrenalectomies/year), especially if performed in challenging cases, including patients with large (> 6 cm) and/or functioning tumors.

UPPER GI—Reflux-Achalasia

O109—Anterior Reconstruction of the Esophageal Hiatus: A Novel Approach for the Laparoscopic Repair of Large Diaphragmatic Hernias

Nir Messer ¹, A. Ben Yehuda², C. Idan³, I. Mimouni³, N. Warnaar⁴, A. Szold¹

¹Assia Medical Group, Surgery, Israel, ²Shamir Medical Center and the Sackler Faculty of Medicine, Tel Aviv, Surgery, Israel, ³Meir Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Surgery, Israel, ⁴Colchester Hospital (and Assia Medical Group), Surgery, United Kingdom

Background: Paraesophageal hernias (PEH) often require a surgical repair. The common approach, laparoscopic primary posterior hiatal,repair with fundoplication, has been associated with a high recurrence rate, even with the use of different meshes to reinforce the primary crural repair. Over the past few years, we have developed a new approach for the repair of these hernias which we believe is more logical, and restores the original anatomy and physiology of the esophageal hiatus. Our technique includes anterior crural reconstruction with routine anterior mesh reinforcement and fundoplication.

Objective: To determine whether anterior crural reconstruction with routine mesh reinforcement and fundoplication in repair of large hiatus hernias is safe and more effective, compared to the classic approach.

Methods: Rational: The esophageal hiatus is composed of the two crura, anchored to the spine posteriorly. This places the GE junction posterior, caudal, and lateral to the fundus (Fig. 1). A classic posterior repair displaces the esophagus anteriorly and cranial to the original position, changing the forces that compose part of the anti-reflux barrier and may push the stomach back to the chest (Fig. 2) with consequent recurrent hernia. The proposed repair restores the original anatomy.

Surgical technique: After complete dissection of the hernia sac and reduction of all herniated organs the esophagus is pushed posteriorly and the diaphragm is repaired with interrupted sutures anterior to the esophagus. The suture line is reinforced with an inverted, U-shaped PVDF coated mesh. An anterior fundoplication is then created unless the patient has severe clinical gastro-esophageal reflux when a complete fundoplication is performed.

Data: Data were collected retrospectively on 178 consecutive patients who had a laparoscopic repair of a symptomatic primary or recurrent PEH between 2011 and 2021, using the above technique. The primary outcome measures were major complication and recurrence, and secondary outcome was patient satisfaction. This was assessed by Imaging tests, gastroscopies, and clinical follow-up with an average of 65 months using a questionnaire, filled over a telephone interview.

Results: Mean patient age at the time of surgery was 62 years, 59% were women. 5% underwent the operation for a recurrent hernia. Mean operative time was 83 min and median operative time was 57 min. No major intraoperative or postoperative complications were recorded. There was no 30-day mortality. Recurrence rate requiring a second operation was 6.7% (12/178) during a mean follow-up of 65 months. Radiological and gastroenterological evidence of mild recurrence was present in 7.3%. Completed telephone questionnaires were obtained in all patients during November 2021.

Conclusion: The anterior crural reconstruction with routine mesh reinforcement and fundoplication is safe, with a reduced recurrence rate compared to reported conventional posterior repairs and should be considered in future studies for further evaluation.

UPPER GI—Reflux-Achalasia

O110—Post POEM Swallow Study: When Is It Necessary?

G. Marom¹, Gabriel Szydlo Shein ¹ , R. Elazary¹, G. Marom¹, M. Abu Gazala¹, R. Brodie¹, A. Rikind¹, Y. Mintz¹

¹Hadassah Ein Kerem, General Surgery, Israel

Background: Per Oral Endoscopic Myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast enhanced swallow studies (CESS) are routinely performed postoperatively to ensure mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM.

Methods: We retrospectively reviewed a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, blood tests as well as imaging studies on POD 1 were evaluated.

Results: 134 patients were included in the study. Sixty-nine (51.49%) of the CESS showed abnormal findings including pneumoperitoneum and 5 of them demonstrated tunnel leaks, which altered the postoperative management. Screening patients for any of the following: Fever, tachycardia or leukocytosis on the first postoperative day (POD-1) had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS.

Conclusions: We suggest that it is not necessary to perform routine contrast enhanced swallow studies on all patients after undergoing POEM as leaks can be screened with clinical or laboratory abnormalities. We propose an algorithm based on objective measurable findings to better select the patients who should undergo this test.

UPPER GI—Gastroduodenal Diseases

O112—Medium and Long-Term Outcomes After Laparoscopic Redo Paraesophageal Hernia Repair

Antoni Molera ¹, S. Fernández-Ananín¹, A. Alonso-Vallès¹, A. Basterra¹, G. Vitiello¹, S. González¹, C. Codina¹, E.M. Targarona¹

¹Hospital de la Santa Creu i Sant Pau. Universitat Autònoma de Barcelona (UAB), Department of General and Digestive Surgery, Spain

Aim: Although laparoscopic hiatal hernia repair has demonstrated to be a safe technique with a satisfactory surgical outcome, the high number of recurrences in the follow-up, with series up to 42%, continues to be the Achilles heel of this morbid condition. Up to 6% of these patients will require a new surgery, technically demanding with a higher morbidity and mortality rate. The aim of this study is to assess intraoperative and postoperative outcomes, as well as the quality of life of patients undergoing laparoscopic redo of paraesophageal hernia (LRPH) in our institution.

Methods: We retrospectively analyzed of a prospectively collected database patients with recurrence of paraesophageal hernia (types II-III-IV) who underwent a LRPH between 2005 and 2021. Variables evaluated included demographics, intraoperative findings, surgical, morbidilty, mortality and health-realated quality of lifeoutcomes.

Results: A total of 39 patients who underwent of LRPH were included in the analysis. The mean age was 59 years (range, 31,81). Primary hiatal hernia repair was approach laparoscopically in 95% (n = 37) of patients. The main symptoms that patients reported was dysphagia in 41% (n = 16), followed by reflux in 33.3% (n = 13). 3 (7.69%) patients required conversion to open surgery (1 due to firm adhesions and 2 to difficulty in identifying the anatomy). A re-Nissen fundoplication was fashioned in 56.7% (n = 22), Toupet funduplication in 20.5% (n = 8) and Dor fundoplication in 7.7% (n = 3). Reinforcement mesh was used in 12.9% (n = 5) of patients (10.3% n = 4 BioA mesh and 2.6% n = 1 proceed mesh). The median length of the surgery was 201.91 min (95-390 min). 8 (20.5%) patients presented intraoperative complications (gastric perforation, pleural opening, hepatic bleeding). 4 (5.1%) patients developed grade IV complications on the Clavien-Dindo scale. 32 (82%) of them completed the quality of life test (GIGLI, Visick) during the follow-up period. Visick score I o II (symptoms resolved or improved) was recorded by 53.12% patients. The mean GIGLI score was 100 (range 52-142). The mean follow-up was 30 months (range 1-104).

Conclusion: In skilled hands and in centers of expertise laparoscopic redo of paraesophageal hernia (LRPH) can offer good postoperative outcomes with an improvement in quality of life.

HEPATO-BILIAIRY & PANCREAS—Liver

O113—Standardization of Laparoscopic Anatomic Liver Resection of Segment 2 by Glissonean Approach

Takeshi Urade ¹ , M. Kido¹, K. Kuramitsu¹, S. Komatsu¹, H. Gon¹, K. Fukushima¹, S. So¹, T. Mizumoto¹, Y. Nanno¹, D. Tsugawa¹, T. Goto¹, S. Asari¹, H. Yanagimoto¹, H. Toyama¹, T. Ajiki¹, T. Fukumoto¹

¹Kobe University Graduate School of Medicine, Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Japan

Background: Anatomic liver resection (ALR) has been established to eliminate the tumor-bearing hepatic region with preservation of the remnant liver volume for liver malignancies. Recently, laparoscopic ALR has been widely applied, but there are few reports about laparoscopic segmentectomy 2. In this study, we present standardization of laparoscopic segmentectomy 2 with surgical outcomes.

Methods: From Jan. 2020 to Dec. 2021, seven patients underwent pure laparoscopic segmentectomy 2 by means of Glissonean approach. Four for hepatocellular carcinoma, 2 for colorectal liver metastasis, and 1 for hepatic angiomyolipoma which was preoperatively diagnosed with hepatocellular carcinoma. In all patients, preoperative 3D simulation images from dynamic CT were reconstructed using a 3D workstation. The layer between hepatic parenchyma and the Glissonean pedicle of segment 2 (G2) was dissected to encircle the root of G2. After clamping or ligation of the G2, 2.5 mg of ICG was injected intravenously to identify the boundaries between the segment 2 and 3 with negative staining method under near-infrared light. Parenchymal transection was performed from the caudal side to the cranial side according to the demarcation on the liver surface and the left hepatic vein were exposed on the cut surface if possible.

Results: The mean operative time for all patients was 281 min. The mean blood loss was 37 ml, and no transfusion was necessary. Estimated liver resection volumes significantly correlated with actual liver resection volumes (r = .61) in all cases. After the operation, there was one patient with asymptomatic deep venous and pulmonary thrombosis who was treated with anticoagulant therapy. The mean length of hospital stay was 8.9 days.

Conclusion: Laparoscopic segmentectomy 2 by Glissonean approach is a feasible and safe procedure.

BARIATRICS—Laparoscopic

O122—Early results of Single Anastomosis Plication Ileal (SAPI) Bypass in Treatment of Obesity

Rita Gudaityte ¹, A. Maleckas²

¹Hospital of Lithuanian University of Health Sciences, Department of Surgery, Lithuania, ²Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Department of Gastrosurgical Research and Education, Sweden

Aims: Laparoscopic single anastomosis plication ileal (SAPI) bypass is a novel bariatric procedure. Few studies have presented early or intermediate results: The aim of this prospective study was to investigate short-term results after SAPI Bypass.

Methods: Between May 2019 and October 2020, 60 patients underwent SAPI bipartition (laparoscopic gastric greater curvature plication and handsewn gastroileal anastomosis 300 cm from caecum) and were followed up to 1 year after operation. Demographics, comorbidities, complications, and percentage of excess body mass index loss (%EBMIL) were analyzed.

Results: Fifty-four women and 6 men with an average age of 45.37 ± 11.06 years and preoperative BMI of 42.92 ± 5.06 underwent SAPI Bypass. Average operation time was 96.92 ± 18.39 min. Average hospital stays 2.45 ± 0.87 days. Postoperative complications were observed in three patients (5%). Two patients had bleeding from gastroileal anastomosis (treated conservatively) and one patient had bleeding in the abdominal cavity, relaparoscopy was performed. Two (3.5%) patients developed anastomotic ulcers within 1 year after surgery. Follow-up rate was 95% after 1 year. Average %EBMIL after 1 month was 25.1 ± 9.43, 55.35 ± 16.81 after 6 months, and 64.98 ± 22.37 after 1 year. Preoperatively GERD was present in 43.3% of patients. Sixteen patients had additional gastrofundoplication and 7 had only cruroplasty. Prevalence of GERD 1 year after operation was 21.7%. Remission rate of type 2 diabetes mellitus and hypertension were 58.3% and 65%, respectively.

Conclusions: Early results after SAPI Bypass is comparable to the results achieved by other weight loss surgery. Long-term follow-up data are needed to define on the efficacy and safety of this new procedure.

ROBOTICS & NEW TECHNIQUES—Colorectal

O123—Randomized Phase III Trial Evaluating the Efficacy of ICG Fluorescence Imaging on Anastomotic Leakage in Laparoscopic Surgery for Rectal Cancer (EssentiAL study)

Ichiro Takemasa ¹, J. Watanabe², M. Kotake³, S. Noura⁴, M. Ikeda⁵, H. Suwa⁶, M. Tei⁷, Y. Takano⁸, K. Munakata⁹, S. Matoba¹⁰, S. Yamagishi¹¹, M. Yasui¹², T. Kato¹³, A. Ishibe¹⁴, M. Shiozawa¹⁵, Y. Ishii¹⁶, T. Yabuno¹⁷, T. Nitta¹⁸, S. Saito¹⁹, M. Watanabe¹⁶

¹Surgical Oncology and Science Sapporo Medical University, Department of Surgery, Japan, ²Yokohama City University Medical Center, Department of Surgery, Gastroenterological Center, Japan, ³Kouseiren Takaoka Hospital, Department of Surgery, Japan,⁴Toyonaka Municipal Hospital, Department of Gastroenterological Surgery, Japan, ⁵Hyogo College of Medicine, Department of Lower Gastroenterological Surgery, Japan, ⁶Yokosuka Kyosai Hospital, Department of surgery, Japan, ⁷Osaka Rosai Hospital, Department of Surgery, Japan, ⁸Southern TOHOKU Research Institute for Neuroscience, Southern TOHOKU General Hospital, Department of Surgery, Japan,⁹Ikeda City Hospital, Department of Gastroenterological Surgery, Japan, ¹⁰Toranomon Hospital, Hepatobiliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Japan, ¹¹Fujisawa City Hospital, Department of Surgery, Japan, ¹²Osaka International Cancer Institute, Department of Gastroenterological Surgery, Japan, ¹³National Hospital Organization Osaka National Hospital, Department of Surgery, Japan, ¹⁴Yokohama City University Graduate School Medicine., Department of Gastroenterological Surgery, Japan, ¹⁵Kanagawa Cancer Center, Department of Surgery, Japan, ¹⁶Kitasato University Kitasato Institute Hospital, Department of Surgery, Japan, ¹⁷Yokohama municipal Citizen’s Hospital, Department of Surgery, Japan, ¹⁸Medico Shunju Shiroyama Hospital, Division of Surgery Gastroenterological Center, Japan, ¹⁹Yokohama Shin-Midori General Hospital, Division of Surgery Gastrointestinal Center, Japan

Aim: We conducted a RCT (EssentiAL study) to confirm the superiority of evaluating the blood flow by ICG Fluorescence Imaging (ICG-FI) as a way to prevent AL after rectal cancer surgery.

Methods: Eligibility criteria included rectal cancer patient planning laparoscopic sphincter-preserving surgery (robotic, taTME is also acceptable), ≤ 12 cm from the anal verge(AV), clinical stage 0-III. Eligible patients were randomized to either blood flow evaluations performed by ICG-FI (ICG ( +) group) or no blood flow evaluations by ICG-FI (ICG (-) group). ICG dose was 12.5 mg/ 5.0 ml. The standard time of acceptable blood flow from ICG administration was set within 60 s. The primary endpoint was the AL rate (grade A + B + C). The planned sample size was 425 cases per arm (two-sided alpha 5%, and power 80%) detecting an AL difference of 6% (13% vs. 7%)

Results: Between Dec 2018 and Feb 2021, 850 cases were randomized. There were 11 cases of discontinuation before protocol treatment and 839 cases (ICG ( +)/ICG (-) group: 422/417 cases) were subject to ITT analysis. Surgical results (ICG ( +) vs ICG (-) group) were approach (laparoscope/robot/taTME): 184/202/36 vs 190/184/43, operative time: 305 vs 318 min, left colic artery preservation: 16.1 vs 15.3%, trans-anal drainage tube: 55.5 vs 57.6%, diverting stoma: 50.1 vs 54.9%, distance from AV to tumor: 8 vs 8 cm, tumor diameter: 3.4 vs 3.2 cm, PM: 12.5 vs 13 cm and DM: 3 vs 3 cm, no significant difference was observed. AL (Grade A + B + C): 7.6 vs 11.8% (RR 0.645, 96%CI 0.422-0.987, p = 0.041), which was significantly lower in the ICG ( +) group. AL (Grade B + C): 4.7 vs 8.2% (p = 0.044), reoperation: 0.5 vs 2.4% (p = 0.004), which were significantly lower in the ICG ( +) group. The rate of additional resection of the oral intestinal tract was 2.4%, the fluorescence time was 25 s.

Conclusions: This RCT showed that ICG ( +) group significantly reduced the AL rate and the reoperation rate. It is recommended to perform blood flow evaluation by ICG-FI for patients scheduled for sphincter-preserving surgery for rectal cancer.

COLORECTAL—Malignant

O124—Is There a Benefit for Routine Histopathological Doughnuts Sampling After High and Low Anterior Resection (AR) in Colorectal Cancer Surgery (CRCS)

Masood Ur Rehman ¹, A. Gendia², M. Nasir², V. Marcu², J. Ahmed²

¹Northampton General Hospital NHS Trust, Colorectal Surgery, United Kingdom, ²Northampton General Hospital, Colorectal Surgery, United Kingdom

Aim: The aim of this study was to evaluate the oncological benefits and cost-effectiveness of routine histologic examination of the doughnuts from stapled anastomoses in patients undergoing high and low anterior resection for rectal cancer.

Methods: A retrospective chart auditing was performed on all consecutive rectal cancer surgery (RCAS) patients performed in NGH from January 2019 till August 2021. Data collected included patient demographic, procedure performed and postoperative histopathological analysis.

Results: Fifty-two patients underwent AR during the given period. A total of 37 patients were included in the study that underwent High and low anterior resection and their doughnuts were sent for histopathological analysis. 62.1% patients were male (n = 23) and 37.9% patients were female (n = 14). The median age at diagnosis was 68.59 years.The histopathology of all resected specimens was adenocarcinoma. Out of 37 patients, 48.6% had undergone low anterior resection (n = 18) and 51.4% had high anterior resection (n = 19). Proximal doughnuts sent in 70.2% patients (n = 26) whereas distal doughnuts in all. Mean distal resection margin from tumor was 21.7 mm and the shortest distance from the tumor to resection margin was 6 mm. All the doughnuts as well as resection margin were negative for any malignancy.

Conclusion: There is no additional oncological benefit is seen in sending routine examination of doughnuts. Only distal doughnut should send in only those in which risk of a positive margin is deemed higher. This will result in significant reduction in cost and time.

COLORECTAL—Malignant

O125—Surgical Transanal Endolumenal Vacuum-Therapy Followed by Early Suture of the Defect for Anastomotic Dehiscence Related to Rectal Surgery

Vasile Bintintan ¹, R. Apostu², V. Fagarasan¹

¹University of Medicine Cluj Napoca, Chirurgie, Romania, ²Universitatea de Medicina Cluj Napoca, Chirurgie, Romania

Introduction: Dehiscence of the anastomosis after low anterior resection of the rectum is quite frequent and leads to a long complicated postoperative course and even to loss of the ability to restore the digestive tract on the long term. Vacuum therapy has the potential to remove the debris accumulated in the presacral space, to promote granulation of tissue and thus to create the prerequisite for healing.

Materials and methods: Vacuum therapy has become our standard of care for treatment of pelvic sepsis after failed coloanal anastomosis an is performed in the operative theatre, by a specialized surgeon using a transanal access. The therapy is started as soon as the diagnosis of suture dehiscence is set and continued in sessions repeated every 3-6 days until the secretion is clear and the walls of the presacral cavity are granulous. At this time the defect is closed surgically usually by a transanal approach. Combined abdominal and perineal reconstruction of the coloanal anastomosis was also performed in cases with complete anastomotic dehiscence.

Results: Our experience include a total of 20 cases of which 13 treated for partial dehiscence of the coloanal anastomosis, 4 treated for complete disruption of the coloanal anastomosis and further 3 cases treated for perineal sepsis related to rectal surgery. Pelvic sepsis was controlled in all cases. Reversal of the protective ileostomy was performed 6 months after healing of the defect. In three cases with persistence of the fistula the ileostomy was transformed in a protective colostomy. Suture of the defect was technically possible in all 17 cases but in 14 cases it failed on the long term, 2 for dehiscence of the rectal stump and one dehiscence of the coloanal anastomosis. These patients still bear a protective stoma. Overall, the method had a 82% success rate for treatment of coloanal fistulas and 85% for treatment of pelvic sepsis related to rectal surgery.

Conclusion: Transanal vacuum therapy should represent the first line treatment for pelvic sepsis related to rectal surgery. We recommend early surgical suture of the defect once the sepsis is controlled and the cavity is clean with granular walls for faster healing and, possibly, better preservation of sphincter function.

COLORECTAL—Malignant

O126—Short and Long-Term Outcomes After Laparoscopic Emergency Resection of Left-Sided Obstructive Colon Cancer; A Nationwide Propensity-Score Matched Analysis

Emma Sophia Zwanenburg ¹

¹Amsterdam UMC, Surgery, The Netherlands

Background: The role of laparoscopy for emergency resection of left-sided obstructive colon cancer remains unclear, especially regarding the impact on survival. The aim of this study was to determine short- and long-term outcomes after laparoscopic versus open emergency resection of left-sided obstructive colon cancer.

Methods: This nation-wide, population-based cohort study compared patients that underwent laparoscopic emergency resection versus open emergency resection between 2009 and 2016, by using 1:3 propensity-score matching. Matching variables included gender, age, BMI, ASA score, prior abdominal surgery, tumor location, cT4, cM1, multivisceral resection, small bowel distention on CT, and subtotal colectomy. Main outcome measures were: 90-day mortality, 90-day complications, permanent stoma, disease recurrence, overall and disease-free survival.

Results: Of 2,002 eligible patients with left-sided obstructive colon cancer, 158 laparoscopic emergency resection patients were matched with 474 open emergency resection patients (Fig. 1). Intentional laparoscopy resulted in significantly fewer 90-day complications (26.6% vs 38.4%, cOR 0.59, 95% CI 0.39-0.87), and similar 90-day mortality. Laparoscopy resulted in better 3-year overall survival (81.0% vs 69.4%, HR 0.54, 95% CI 0.37-0.79) and disease-free survival (68.3% vs 52.3%, HR 0.64, 95% CI 0.47-0.87). Multivariable regression analyses of the unmatched 2,002 patients confirmed an independent association of laparoscopy with fewer 90-day complications and better 3-year survival (Fig. 2).

Conclusions: This population-based study with propensity-score matched analysis suggests that intentional laparoscopic emergency resection might improve short- and long-term outcomes in patients with left-sided obstructive colon cancer compared to open emergency resection, warranting confirmation in future studies. Management of those patients in the emergency setting requires proper selection for intentional laparoscopic resection if relevant expertise is available, thereby considering other alternatives to avoid open emergency resection (i.e. decompressing stoma).

Fig. 1 Flow-chart of patient selection

COLORECTAL—Malignant

O127—Late Anastomotic Leakage After Rectal Cancer Surgery with Defunctioning Stoma—Can We Successfully Avoid Permanent Stoma?

Bojan Krebs ¹ , A. N. Arslani¹, I. A. Ivanecz¹

¹UCC Maribor, Slovenia, Abdominal Surgery, Slovenia

Introduction: Anastomotic leakage after low anterior resection still represents a major problem. Although surgeons successfully managed to lower the early leakage rate with the aid of defunctioning stoma, the problem with late anastomotic leakages still persists. Unfortunately, we only become aware of this problem when we intend to close the defunctioning stoma. Patients are usually asymptomatic but could develop severe complications in case of stoma closure in such a case.

Methods: We searched Pubmed and Medline for articles about the late anastomotic leakage rate after rectal cancer surgery with diverting stoma and its treatment. We also performed a retrospective cohort study of all patients operated on rectal cancer at our department between 2001 and 2017 with special emphasis on anastomotic leakage.

Results: We found quite a few of articles about late anastomotic leakage but only few of them about the therapy. The treatment alternatives include nonoperative (endosponge, drainage, fibrin glue, antibiotics, wait and see approach..), and operative (transanal closure of an anastomotic defect, resection of the anastomosis with construction of a permanent colostomy, anastomotic redo operation) measures. We couldn’t find any study about this issue. Between 2001 and 2017 we operated on 1159 patients with rectal cancer. There were 679 cases with anastomosis and anastomotic leakage rate was 5,3%. Most of the patients had an early anastomotic leakage which was treated with drainage and diverting stoma if not already presented. Other options include takedown of the anastomosis and Hartmann procedure. Patients with late stoma were predominately treated with wait and see approach and in most of those patients stoma was never closed

Conclusions: There are no firm guidelines for the treatment of late anastomotic leakage. If possible such complications should be treated in high volume centre with an individualized approach. Even so many patients will have to live with a stoma for the rest of their lives.

COLORECTAL—Malignant

O128—Experience Establishing a Transanal Minimally Invasive Surgery Service in a UK District General Hospital 2018–2021

Giles Goatly ¹ , M. Badawi¹, Y. El-Dhuwaib¹

¹Conquest Hospital, East Sussex Healthcare NHS Trust, General and Colorectal Surgery, United Kingdom

Aim: Transanal minimally invasive surgery (TAMIS) is an established natural orifice surgical technique for local excision of rectal pathology. Our aim is to assess the feasibility of establishing the service in a United Kingdom based National Health Service District General Hospital.

Methods: TAMIS procedure was first performed in the hospital in May 2018, we reviewed our results up to 31st Dec 2021. TAMIS was offered for patients with benign histology or to those patients who were not fit for major colorectal surgery. Data on patient demographics, length of stay (LOS), complications, return to theatre, recurrence of the disease, further surgery, and follow up to 31st Dec 2021 were recorded retrospectively. All patients were discussed in MDT and underwent a pre-operative magnetic resonance imaging (MRI), Flexible sigmoidoscopy. Patient underwent 3 monthly MRI, Flexible sigmoidoscopy, and computed tomography scan for the first year followed by 6 monthly for the following year.

Results: A total of 46 patients (29 male and 17 female) underwent TAMIS procedure in the study period. The mean age was 72 (51-90 years old) with the average distance of lesion from anal verge 9.1 cm (2-15 cm). The average operative time was 78 min (35-180). In total 8 patients had confirmed malignant pre-operative histology but were not fit for major colorectal resection, a further 6 patients were found to have rectal cancer on post-operative histology. 14 patients had full thickness TAMIS resections with the rest partial thickness, 1 TAMIS procedure was abandoned as the tumour was visibly more advanced than the preoperative histology/imaging had suggested. 2 patients were readmitted with self-limiting rectal bleeding (Clavien-Dindo grade 2). There was no surgical mortality, the average LOS was 1.5 days(8 h-4 days). 4 patients underwent further resection surgery due to threatened or incomplete margins, of these 2 had no residual tumour, and one had pT3 tumour. Of the patients with rectal cancer on TAMIS histology that did not proceed to surgery, there was no recurrence or metastasis noted on follow up to date, median 18.4 months (3.5-37.8).

Conclusion: With appropriate patient selection and multi-disciplinary team support, a flourishing TAMIS service can be safely and successfully established in a district general hospital setting with favourable results.

COLORECTAL—Malignant

O129—Adhesion Formation After Laparoscopic Versus Open Resection of Locally Advanced Colon Cancer: An Evaluation by Standardized 18 Months Re-exploration

Sophie Zwanenburg ¹, D. Wisselink¹, C. Klaver², A. Brandt³, A. Bremers⁴, J. Burger⁵, W. van Grevenstein⁶, P. Hemmer⁷, I. De Hingh⁵, N. Kok⁸, M. Wiezer⁹, J. Tuynman¹, P. Tanis¹⁰

¹Amsterdam UMC, Surgery, The Netherlands, ²Amsterdam UMC, Surgery and Gastroenterology, The Netherlands, ³Erasmus MC, Surgery, The Netherlands, ⁴Radboud UMC, Surgery, The Netherlands, ⁵Catharina Hospital, Surgery, The Netherlands, ⁶UMC Utrecht, Surgery, The Netherlands, ⁷UMC Groningen, Surgery, The Netherlands, ⁸Antoni van Leeuwenhoek hospital/Netherlands Cancer Institute, Surgery, The Netherlands, ⁹St. Antonius Hospital, Surgery, The Netherlands, ¹⁰Amsterdam UMC & Erasmus MC, Surgery, The Netherlands

Background: Adhesion formation after surgery for colon cancer can result in significant long-term morbidity, and hampers re-exploration for recurrence. The aim of this study was to evaluate the incidence and severity of adhesions after laparoscopic versus open resection of locally advanced colon cancer.

Method: This planned side study of the COLOPEC randomized controlled trial, that primarily determined the effectiveness of adjuvant intraperitoneal chemotherapy after resection of c/pT4N0-2M0 or perforated colon cancer (accrual April 2015—January 2017), included all patients who underwent 18-months diagnostic laparoscopy for peritoneal staging. Standardized assessment of adhesions was part of the study protocol. Outcome parameters were the incidence of adhesions, and severity according to the Dowson-score (0-10; severe if ≥ 6).

Results: Out of 204 patients, 128 underwent a diagnostic laparoscopy at 18 months. Re-exploration revealed adhesions in 36 of 75 patients (48.0%) after initial laparoscopic resection, and in 46 of 53 patients (88.5%) after open resection (p < 0.001). The mean Dowson score after laparoscopic resection was 2.4 versus 5.3 after open resection (p < 0.001). Open resection was independently associated with increased risk of adhesions (HR 4.43, 95% CI 1.47—13.38) as well as severe adhesions (HR 3.35, 95% CI 1.16—9.72), when adjusted for multivisceral resection, perforations, and prior abdominal surgery.

Conclusion: Laparoscopic resection of locally advanced colon cancer reduces both the occurrence and severity of adhesion formation at 18 months postoperatively, as compared to open resection. Trial Registration: NCT02231086 (Clinicaltrials.gov)

ROBOTICS & NEW TECHNIQUES—Colorectal

O130—A Pilot Study to Assess the Safety and Feasibility of Sentinel Lymph Node Identification in Colon Carcinoma Using Indocyanine Green

Daan Sikkenk ¹, A.J. Sterkenbrug¹, T.A. Burghgraef², H. Akol³, M.P. Schwartz³, R. Arensman⁴, P.M. Verheijen², W.B. Nagengast⁵, E.C.J. Consten¹

¹Meander Medical Centre/UMC Groningen, Surgery, The Netherlands, ²Meander Medical Centre, Surgery, The Netherlands, ³Meander Medical Centre, Gastroenterology, The Netherlands, ⁴Meander Medical Centre, Pathology, The Netherlands, ⁵UMC Groningen, Gastroenterology, The Netherlands

Aims: Patients with cT1-2 colon carcinoma have a relatively low risk of lymph node metastases. Segmental resections may not be necessary in tumours without lymph node metastases resulting in overtreatment in 92% and 83% of patients with respectively T1 and T2 colon tumours. A local excision accompanied by sentinel lymph node identification (SLNi) in colon carcinoma and a minimal invasive patient-tailored lymphadenectomy, could improve staging and reduce morbidity in the future. This pilot study aims to assess safety and feasibility of SLNi using endoluminally, peritumorally injected indocyanine green (ICG) in patients with cT1-2N0M0 colon carcinoma.

Methods: This prospective feasibility study included ten patients with cT1-2N0M0 colon carcinoma. During robot-assisted surgery, a gastroenterologists submucosally injected 20 mg (4 ml) of ICG in four quadrants around the tumour. Thereafter, the near-infrared camera of the Da Vinci Xi was used for SLNi and the sentinel lymph node was marked with a suture for postoperative ultrastaging. D2 lymph node dissection was performed after SLNi. Colonoscopy time (start to finish of the colonoscopy), time to first SLNi after ICG injection and “SLNi time” (from start colonoscopy to resuming dissection) were measured. Furthermore, morbidity and pathological outcomes were noted.

Results: In all ten patients at least one SLN was identified (mean: 2.3 SLNs) and there we no tracer (injection) related adverse events. Two patients had lymph node metastases that were present in the SLN and no patients had metastases in other lymph nodes when sentinel lymph nodes were negative. Five patients had a T3 tumour on pathological examination. Median colonoscopy time was 12 min, time for first SLNi was 6 min and SLNi time was 30.5 min.

Conclusion: SLNi using endoluminally, peritumorally injected ICG in ten patients with cT1-2N0M0 colon carcinoma was safe and feasible. SLNi was performed in an acceptable timespan. All lymph nodes with metastases were detected with SLNi. This pilot study warrants more research of SLNi in colon carcinoma, and this technique might be used to reduce morbidity and improve staging in early-stage colon carcinoma.

ROBOTICS & NEW TECHNIQUES—Technology

O131—Contrast-Free Bowel Perfusion Quantification During Minimally Invasive Colorectal Resections Using Hyperspectral Imaging

Manuel Barberio ¹, S. Benedicenti², A. Lapergola³, M. Mita², V. Barbieri², F.Rubichi, A. Altamura, B. Jansen-Winkeln⁴, M. Diana¹, M. Viola²

¹IRCAD France, Research, France, ²Panico Hospital, Tricase, Surgery, Italy, ³Nouvelle Hopital Civil, Surgery, France, ⁴Leipzig University Hospital, Surgery, Germany

Aims: Optimal intestinal perfusion is required to reduce anastomotic leak (AL)’s risk during gastrointestinal procedures. Fluorescence angiography is widely used to assess perfusion intraoperatively. However, it requires intravenous contrast agent injection, and it does not provide objective information. Hyperspectral imaging (HSI), a contrast-free optical imaging technology, previously validated during preclinical trials, quantifies accurately tissue oxygen saturation (StO2).

Aim of this work is to explore the usefulness of this novel technology to quantify intestinal perfusion intraoperatively during colorectal surgeries and compare it to visual ischemia evaluation.

Methods: In 52 patients undergoing minimally invasive colorectal resections, after division of the marginal artery, the proximal bowel’s blood-flow was assessed first visually and then using an HSI-camera. The distance between the clinical transection line (CTL) and the HSI-based transection line (HTL) was measured. StO2 was quantified at 7 regions of interest (ROI): at CTL and at each centimeter, for 3 cm distally and proximally to CTL, respectively. In case of HTL/CLT discrepancy, CTL was always moved in correspondence of HTL.

Results: In 51 patients the HTL was clearly visible as prevalently straight demarcation line and the overall StO2 at the distal ROIs was significantly lower than at the proximal ROIs (p-value < 0.001). In one patient undergoing ultra-low anterior resection and neoadjuvant therapy (NT) the HTL was irregular and hardly identifiable. This patient developed an AL, successfully treated with Endo-VAC-therapy. In 26 patients CTL differed from HTL (Discrepancy Group, DG; mean difference = 9 ± 13 mm). In the DG the StO2 at CTL measured 42.31 ± 14.99%, which was significantly lower (p-value < 0.001) than in the non-DG 65.88 ± 12.39%. Ligation at the origin of the inferior mesenteric artery (IMA) (38 patients) and previous neoadjuvant treatment (NT) (10 patients) were associated with CTL/HTL discrepancy (p-value = 0.003 and 0.03, respectively). In DG, CTL always fell within the ischemic area. Only in 1 patient CTL was positioned within the perfused area, 40 mm distally from the HTL. As a result, the HSI-analysis allowed to spare 40 mm of bowel length.

Conclusion(s): HSI seems to be a reliable instrument to quantify bowel perfusion intraoperatively, since human vision is inaccurate, as demonstrated by the CTL/HTL discrepancy in 50% of cases. The clinical value of HSI in reducing AL needs to be assessed with larger and specifically designed trials.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O132—One-Staged Approach to Treat Cholecystocholedocholithiasis: A Valid Alternative for Elective and Emergency Setting in a Large Group of Consecutive Patients

Manuel Barberio ¹, A. Lapergola², M. Gregori³, F. Maurichi⁴, S. Gallina⁴, P. Benedicenti⁴, M.G. Viola¹

¹Cardinale Panico, General Surgery, Italy, ²Nouvel Hôpital Civil, Strasbourg, Department of Digestive and Endocrine Surgery, France, ³Policlinico Casilino, Rome, General Surgery, Italy, ⁴Cardinale Panico, Endoscopy Unit, Italy

Aim: Cholecystocholedocholithiasis (CCL) is present in up to 18% of patients undergoing laparoscopic cholecystectomy (LC) for gallbladder stones. Commonly, CCL is treated using a two-staged approach, represented by endoscopic retrograde cholangiopancreatography (ERCP), followed by LC. This safe and effective option is widely adopted. However, only 10–60% of patients have common bile duct (CBD) stones at the time of ERCP, thus exposing a number of patients to unnecessary ERCPs, causing post-interventional pancreatitis in 3% to 15% of cases. An alternative approach to treat CCL is represented by the one-staged laparoscopic-endoscopic rendezvous (LERV) technique. Given the selective top-to-bottom CBD cannulation, LERV reduces the risk of post-interventional pancreatitis and failed CBD clearance. Additionally, LERV is performed exclusively in patients presenting CBD stones at intraoperative cholangiography, thus avoiding unnecessary ERCPs. Despite its advantages, given the logistic burden to coordinate different specialties, LERV is performed in a few centers. Here we present the retrospective analysis of LERVs performed at our center, in which endoscopy and surgery work in close synergy, being included within the same department.

Methods: All consecutive patients undergoing LERV at our Surgical Department between January 2014 and December 2021 were included. Total operative time, successful CBD stone clearance, postoperative complications (POC), length of hospital stay (LOS) and 30-days recurrence were analyzed.

Results: 179 patients were included. 87 were elective LEVR, whereas 82 were emergency LEVR. Median operative time was 118.31 ± 27.71 min. LOS was 4.06 ± 2.96 days. No difference in terms of POC or recurrence rate was encountered between emergency and elective LEVR. 5 patients developed post-operative cholangitis and underwent ERCP for CBD stones recurrence, 1 patient had a cystic duct leak and underwent laparoscopy on post-operative day1; 1 showed a post-procedural pancreatitis, treated conservatively. 7 patients had CBD stone recurrence. Younger patients were more likely to develop recurrence (p 0.003) and patients with increased cholestasis blood parameters were prone to develop POC and recurrence (p 0.03).

Conclusions: LEVR is safe, with a relatively low complication rate even under emergency setting and it allows to treat CCL within a single procedure, thus sparing the patient additional anesthesia and decreasing post-ERCP pancreatitis.

COLORECTAL—Benign

O133—Short and long-term results of a randomized clinical trial comparing endoscopic versus conventional treatment of pilonidal sinus.

Michele Manigrasso ¹ , G.D. De Palma², M. Milone²

¹"Federico II" University of Naples, Advanced Biomedical Sciences, Italy, ²"Federico II" University of Naples, Clinical Medicine and Surgery, Italy

Video-assisted ablation of pilonidal sinus (VAAPS) is a new minimally invasive treatment based on the complete removal of the sinus cavity with a minimal surgical wound. In the new era of minimally invasive surgery, recent studies encouraged the adoption of endoscopic approaches as the most effective way to treat (pilonidal sinus disease) PSD but little is known about long-term results of minimally invasive procedures.

A total of 145 patients with chronic non recurrent pilonidal sinus were enrolled for this randomized controlled trial.

The primary end point of the study was time off work. Secondary end points were the rates of operative success and perioperative complications (infection and recurrence), operative time, patient satisfaction, and intraoperative and postoperative pain ratings.

Furthermore, long-term recurrence rate and cost-effectiveness results were analysed.

Of the 145 patients, 60 (78.9%) were male and 16 (21.1%) were female in the minimally invasive treatment group, and 54 (78.3%) were male and 15 (21.7%) were female in the conventional treatment group. The mean (SD) age of the patients was 25.5 (5.9) years in the minimally invasive treatment group and 25.7 (5.3) in the conventional treatment group. In the minimally invasive treatment group, mean (SD) time off work was significantly less compared with the conventional treatment group (1.6 [1.7] vs 8.2 [3.9] days; P < .001). Mean (SD) operative time was significantly longer in the minimally invasive treatment group (42.9 [9.8] minutes) vs the conventional treatment group (26.5 [8.7] minutes), P < .001. Although the overall complication rate was similar in both groups, there were fewer infections (1 [1.3%] vs 5 [7.2%]; P = .10) recorded in the minimally invasive treatment group. Similarly, patients enrolled in the minimally invasive treatment group expressed significantly less pain and higher satisfaction.

The follow-up rate was 97% at 5 years for a total of 74 patients assigned to the minimally invasive treatment group and 67 patients assigned to the conventional Bascom cleft lift treatment group.

Long-term data confirm that the recurrence rate was similar in both groups and, in minimally invasive patients, there were a higher satisfaction and better cosmetic results. Costs analysis revealed improved outcome in favour of VAAPS with a much lower mean global cost.

In the new era of minimally invasive treatment surgery, pilonidal sinus could become a disease treated with an endoscopic approach. Although additional studies are needed to provide a definitive conclusion, our results encourage considering the adoption of this treatment as the most effective way to treat pilonidal sinus.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O141—Defining Textbook Outcomes Following Elective Laparoscopic Cholecystectomy

James Lucocq ¹ , J. Scollay¹, P. Patil¹

¹Ninewells Hospital, Department of General and Upper GI Surgyer, United Kingdom

Introduction: A textbook outcome (TO) is a composite measure that defines the ideal outcome following an operation. Reporting of rates of TO and determinants of achieving TO can inform individualised patient consent that recognises the risk of all forms of morbidity. The TO criteria for elective laparoscopic cholecystectomy (ELLC) have not been defined. The present paper utilises a comprehensive analysis of peri-operative morbidity following ELLC to formulate the criteria for TO, report the rate of achieving TO and identify factors predisposing to TO failure.

Methods: All patients who underwent ELLCs in one health board between January 2015 and January 2020 were considered for inclusion in the study. Criteria for a TO included a peri-operative course in the absence of subtotal cholecystectomy, conversion to open, intra-operative complication, post-operative complication (Clavien-Dindo ≥ 2), post-operative imaging, re-intervention, length of stay ≥ 48 h, re-admission or mortality. The rate of TO in the cohort was reported and predisposing factors for failing to achieve TO were found using multivariate logistic regression.

Results: 2166 ELLC were performed (age[range], 52[13-92]; M:F,1:2.7) and 85.5% (1851/2166) had a TO. Variables associated with TO failure included increasing ASA, previous biliary-related admissions, cholecystitis, pre-operative ERCP and pre-operative cholecystostomy (p < 0.05).

Discussion: The present study defines a textbook outcome for ELLC and reports a significant rate of textbook outcome failure (14.5%). Reporting of the TO rate for ELLC allows patients to quantify the aggregate risk of all morbidity of the procedure. Acknowledgement of the risks factors for TO failure identified in the present study can be utilised to guide an individualised patient consent process.

HEPATO-BILIAIRY & PANCREAS—Liver

O142—Implementing a Robotic Liver Resection Program Does Not Always Require Prior Laparoscopic Experience

Lorenzo Bernardi ¹ , E. Balzano¹, P. De Simone¹

¹Pisa University Hospital, Hepato-biliary and Liver Transplantation Unit, Surgery, Italy

Background: Preliminary experience in laparoscopic liver surgery is usually suggested prior to implementation of a robotic liver resection program.

Methods: This was a retrospective cohort analysis of patients undergoing robotic (RLR) versus laparoscopic liver resection (LLR) for hepatocellular carcinoma at a center with concomitant initiation of robotic and laparoscopic programs

Results: A total of 92 consecutive patients operated on between May 2014 and February 2019 were included: 40 RLR versus 52 LLR. Median age (69 vs. 67; p = 0.74), male sex (62.5% vs. 59.6%; p = 0.96), incidence of chronic liver disease (97.5% vs.98.1%; p = 0.85), median model for end-stage liver disease (MELD) score (8 vs. 9; p = 0.92), and median largest nodule size (22 vs. 24 mm) were similar between RLR and LLR. In the LLR group, there was a numerically higher incidence of nodules located in segment 4 (20.0% vs. 16.6%; p = 0.79); a numerically higher use of Pringle’s maneuver (32.7% vs. 20%; p = 0.23), and a shorter duration of surgery (median of 165.5 vs. 217.5 min; p = 0.04). Incidence of complications (25% vs.32.7%; p = 0.49), blood transfusions (2.5% vs. 9.6%; p = 0.21), and median length of stay (6 vs. 5; p = 0.54) were similar between RLR and LLR. The overall (OS) and recurrence-free (RFS) survival rates at 1 and 5 years were 100 and 79 and 95 and 26% for RLR versus 96.2 and 76.9 and 84.6 and 26.9% for LLR (log-rank p = 0.65 for OS and 0.72 for RFS).

Conclusions: Based on our results, concurrent implementation of a robotic and laparoscopic liver resection program appears feasible and safe, and is associated with similar oncologic long-term outcomes.

Dear editors, this abstract and the relative article have been recently published on Surgical Endoscopy, however we would like to present our work at the next EAES congress as in the meeting in Barcelona the struggle between robotics and laparoscopy in the field of liver surgery has been a really hot topic. We believe that our experience is quite a unique as surgeons generally start robotics after having achieved solid experience in laparoscopy in the field of liver surgery. This would undoubtely enhance the discussion on the topic and provide an alternative point of view. Moreover we could provide an overview on the implementation of minimally invasive liver surgery in liver transplant centres.

ROBOTICS & NEW TECHNIQUES—Technology

O143—Development of a Surgical Activity Model of Laparoscopic Cholecystectomy for Co-operation with Cognitive Surgical Robots

Rayan Younis ¹, A. Kisilenko¹, S. Bodenstedt², P.M. Scheikl³, C. Kunz³, M.T.J. Daum¹, B. Müller¹, T. Davitashvili¹, P.A. Wise¹, F. Mathis-Ullrich³, F. Nickel¹, S. Speidel², B.P. Müller-Stich¹, M. Wagner¹

¹Heidelberg University Hospital, General, Visceral and Transplantation Surgery, Germany, ²National Center for Tumor Diseases Dresden, Translational Surgical Oncology, Germany, ³Karlsruhe Institute of Technology, Health Robotics and Automation Lab, Germany

Aims: Robot-assisted surgery is finding novel applications in many surgical specialties. However, current systems only provide telemanipulation, not an active robotic assistance. This is because of the high complexity of minimally invasive procedures. In order to provide the surgeon with robotic assistance in the right moment, the procedures need to be broken up in smaller entities that can be understood and reproduced by a machine: using machine learning and artificial intelligence, a cognitive surgical robot could then assist the surgeon actively. For this purpose, we developed a surgical activity model for laparoscopic cholecystectomy (LC).

Methods: An activity model for LC was created comprising 7 surgical phases, 9 actions, 4 actors, 21 instruments and 23 anatomical targets. At any given point of the procedure, the action of the respective hand of the surgeon should be attributed to an instrument and a target structure. Then, the model was validated on n = 4 videos of LC performed on explanted porcine livers in a training setting and n = 5 videos of LC from the HeiChole dataset on real patients in a clinical setting. An annotation ruleset was established and the video data were annotated using the ANVIL annotation software.

Results: The total length of the videos with explanted porcine livers was 1,8 h. The total length of the HeiChole videos was 2,5 h. During the procedures on explanted porcine livers, 2 actors performed 560 distinct activities (± 293) with 7 different actions, 6 different instruments and 8 different target structures. During the procedures of the HeiChole dataset, 3 actors performed 663 distinct activities (± 71) with 7 different actions, 8 different instruments on 16 different target structures. For example, the assistant’s right hand grasped the gallbladder 3,8 times and held it 19,1 min on average. The target of blunt dissection was the hilum of liver in 33,9% of activities.

Conclusions: A model to break up LC into distinct activities was successfully developed and validated on training as well as clinical operation videos. In a next step, the model and dataset presented here can be used to train an artificial intelligence for automatic recognition of activities and, in perspective, to train autonomous cognitive surgical robots to co-operate and become active surgical assistants. For machine learning algorithms to reliably perform with this model, more training data needs to be generated. Therefore, it is key for future datasets to be open to the public.

HERNIA-ADHESIONS—Abdominal wall hernia

O144—Robotic Transabdominal Morgagni Hernia Repair in Adults with Primary Closure and Mesh Placement: A Report of Three Cases

Elsa Beltrami ¹ , A. Marano¹, E. Gelarda¹, P. Geretto¹, F. Borghi¹, M. C. Giuffrida¹

¹Santa Croce e Carle Hospital, Department of General Surgery, General and Oncologic Surgical Unit, Italy

Aims: Morgagni hernia (MH) is a rare, congenital anteromedial diaphragmatic defect. Once diagnosed, surgery is recommended due to the increased risk of visceral strangulation and other complications. In the last 20 years, the use of minimally invasive surgery for MH repair in adults has been described in literature but only few experiences have been recently reported about the application of the robotic approach. The aim of this report is to describe three cases of robotic repair of MH in adults performed in a single Institution to better delineate the potential technical advantages of this emerging approach to this rare condition.

Methods: Between June 2019 to December 2021, three consecutive patients with symptomatic MH underwent full robotic hernia repair. We used da Vinci® Si™ system for the first case, and the Xi™ system for the last two cases. Five trocars were used to gain access to the abdomen. All patients underwent hernia reduction, primary defect closure (in all but one case) with self-locking barbed sutures, and implant of fully resorbable monofilament mesh (2 cases) and composite mesh (one case) for reinforcement that was fixed with polyester suture and/or absorbable tacks. Sac excision was performed in only one patient.

Results: Robotic repair of Morgagni hernia was successfully performed in all patients. Mean operative time was 219,6 min. There were no intraoperative complications. Additional interventions, including a repair of a transverse colon serosal tear during the reduction of hernia contents, occurred in 1 case. Average length of stay was 2 days. There were no 30-day postoperative complications.

Conclusion(S): Robotic approach for transabdominal MH repair in adults is a safe and feasible alternative minimally invasive technique that allows for primary tension-free repair with mesh reinforcement. This procedure benefits of the well-known robotic technical advantages especially for the diaphragmatic defect suture and mesh fixation in a narrow operative field.

BARIATRICS—Laparoscopic

O145—Comparative Study Between Single Anastomosis Sleeve Jejunal Bypass, Sleeve Gastrectomy and One Anastomosis Gastric Bypass: A Prospective Randomized trial

Mohamad Elrefai ¹ , A. Hussien¹, A. Elgeidie¹, H. Ezzat¹

¹Gastrointestinal Surgery Center, Surgery, Egypt

Background: A variety of bariatric procedures are being practiced nowadays. Laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB) are two commonly practiced bariatric procedures. Recently, single anastomosis sleeve jejunal bypass (SASJ) has emerged as a novel effective procedure with a decreased risk of malnutrition due to the presence of two pathways for food. Herein, we compared outcomes of these three procedures regarding short-term weight loss, complications, comorbidity resolution and quality of life.

Patients and Methods: We included a total of 60 cases in this prospective randomized study, and they were divided into three equal groups; SASJ, LSG and OAGB groups. The three procedures were performed by the same surgical team adapting standardized techniques. Weight loss parameters were our primary objectives, while secondary outcomes included post-operative complications, nutritional status, improvement/resolution of comorbidities and quality of life.

Results: Operative time was significantly prolonged in the SASJ group, compared to the other two groups. Nevertheless, the incidence of post-operative complications did not significantly differ between the three groups, apart from GERD, that was more encountered in LSG group (20% of cases). Percentage of total weight loss (%TWL) were comparable among the 3 procedures; (SASJ 39.4 and 56.85%), (LSG 46.05 and 65.6%) and (OAGB 43 and 61.4%) at 6 and 12 months respectively. Comorbidity improvement, quality of life and nutritional status didn’t differ among the three study groups.

Conclusion: SASJ bypass is an effective bariatric procedure regarding weight loss and comorbidity resolution, with a safe perioperative outcome comparable to OAGB and LSG.

ROBOTICS & NEW TECHNIQUES—Technology

O146—Trainingcurricula and Facilities in Laparoscopic Surgery in Germany: A National Survey

Florian Oehme ¹ , O. Al-Aqiqi¹, S. Schmidt¹, A. Schneider¹, F. von Bechtolsheim¹, J. Weitz¹, M Distler¹

¹University Hospital Carl-Gustav-Carus, TU Dresden, Visceral-, Thoracic- and Vascular Surgery, Germany

Introduction: Since the first use of modern laparoscopy more than 40 years ago, the possibilities of laparoscopy have developed rapidly. In contrast to the complexity and the demands of laparoscopy, an evident lack of a uniform training structures and standardisation exist. The aim of this national survey was to raise awareness for the discrepancy between the required standardisation in laparoscopic training curricula and and the current day-to-day routine in individual clinics.

Methods: The minimal-invasive laparoscopy research group of the Visceral, Thoracic and Vascular Surgery Department of the University Hospital Dresden conducted a nationwide survey between 10/21—12/21. First, all surgeons working in Germany were identified and then an online invitation was sent to participate in this survey. The invitation was either sent directly to the physician or distributed centrally by the head physician of the respective hospital. After the initial mailing, a total of 5 reminders to participate in the survey, which was conducted via LimeSurvey, was send out.

Results: A total of 1008 (34.3%) of 2940 surgeons contacted took part in this survey. The distribution was as follows: 263 (26.1%) residents, 147 (14.6%) junior consultants, 261 (25.9%) senior consultants and 333 (33.1%) Chief/Co-Chiefs. A standardised laparoscopic training curriculum was available to 300 (29.8%) surgeons, with laparoscopic training facilities available to 579 (57.4%). Overall, 241 (23.9%) surgeons from laparoscopy-certified training centres participated, with a significant (p-value < 0.001) higher rate of standardised curricula available at their institutions. When asked about satisfaction (measured between 0-100 on a lickert scale) with laparoscopic training opportunities (i), laparoscopic intraoperative teaching (ii) and available laparoscopic training time, residents were significantly (p-value < 0.001) more dissatisfied (scoring 19-42) than corresponding consultants.

Conclusion: This national survey revealed a clear lack of standardised training curricula and access to training opportunities in laparoscopic surgery in Germany. Even more seriously, the perception of the quality of intraoperative training time and time in dry labs differs significantly between residents/junior consultants and Chiefs/Co-Chiefs. Central standardisation with a focus on a laparoscopic training curriculum should be the consequence.

COLORECTAL—Benign

O147—Successful Endoscopic Closure of Chronic Colocutaneous Fistulas; The Use of Padlock Clip

Ahmed Baban ¹, K. Shalli²

¹Hawler Medical University, Surgery, Iraq, ²University Hosptial Wishaw, Surgery, United Kingdom

Aims: Management of chronic colocutaneous fistulas remains a challenging delima in unfit patient were surgery as a defenitive treatment is not possible. Limited reports on theraputic endoscopic procedures has been shown recently. We present the use of endoscopic Padlock clip as a treatment option.

Methods: A retrospective case analysis was undertaken of patients who had undergone endoscopic closure of chronic colocutaneous fistulas (postoperative complication of an obstrcuted recurrent hernia repair) using padlock clip technique and outcomes assessed. Electronic case note, Imaging, subsequent endoscopic reports and patient follow up at outpatient clinic were reviewed.

Results: A 65 years female with morbid obesity and comorbidity had a colo-cutaneous fisutla for 3 years. CT scan suggested it is arising from transverese colon. Initial endoscopic assessment confirmed the site of the fistula followed by endoscopic padlock clip application (Fig. 1). At follow up clinic and endoscopy the fistula was healed (Fig. 2).

Conclusion: Endoscopic padlock clips are a successful and safe method to close chronic colocutaneous fistulas in patient that require definitive management but are not fit for a surgical intervention such as in our case. After 18 months of follow up fistula remains completely closed. Endoscopic closure using padlock clips can be offered as an alternative option for treatment of fistulas but it is effectiveness need further assessment in a larger group of patients.

COLORECTAL—Benign

O148—Multicentre Study on Management of Right Iliac Fossa Pain in Young Females: A Need for Recommendation

Ahmed Baban ¹, K. Mackenzie², A. Elamin³, K. Shalli³

¹Hawler Medical University, Surgery, Iraq, ²University of Glasgow, Medical School, United Kingdom, ³University Hospital Wishaw, Surgery, United Kingdom

Aim: Right iliac fossa (RIF) pain in young women remains a diagnostic challenge. It is one of the commonest surgical emergency presentations, however a sub-group of patients have no definitive diagnosis. Current tools used includes observations, routine investigations, ultrasound and laparoscopy. However more specific recommendations for a better management of this cohort are required.

Methods: Retrospective multi-centre (two different cultural backgrounds) analysis of females aged 17 to 35 acutely admitted with RIF pain over a five-month period was conducted. The length of stay, current tools used for investigation (including laparoscopy) and cost were calculated. Pregnant women and those with a definitive picture of appendicitis were excluded.

Results: A total of 154 patients with RIF pain were studied. 77 (50%) were sent home within 24 h. Of the remaining 77 patients, 21 laparoscopies were performed, 10 had positive findings (47.6%), 9 appendicitis and 1 carcinoid tumour. Only two CT scans were performed, both indicated positive cases that required surgery. Patients without a definitive diagnosis had an average hospital stay of 4 days compared to 2 when successfully managed conservatively. Cost calculated for negative laparoscopy was £2915 and £469 for CT scan combined with one-day stay.

Conclusion: This study demonstrated that a sub-group of young females with RIF pain would benefit from early CT scan (that is highly sensitive), to definitively diagnose or rule out appendicitis. This would be more cost effective and help to avoid an un-necessary invasive procedure as well as prolonged hospital stays. Guidelines are needed for more timely diagnosis and optimization of management in this cohort.

COLORECTAL—Benign

O149—Indocyanine Green Use in Minimally Invasive Colon Resections—First Years in Ponderas Academic Hospital

Clarisa Bîrlog ¹, V. Tomulescu², G. Filip¹, F. Turcu¹, S. Filip¹, B. Smeu¹, C. Copăescu¹

¹Ponderas Academic Hospital, General Surgery, Romania, ²Ponderas Academic Hospital, Colorectal, Romania

Introduction: Near-infrared (NIR) guided surgery is becoming the new standard for intraoperative visualization of various anatomical structures. Using fluorophores that are visible only after excitation from specific imaging systems increases the precision and enhances the decisional process in the operating room. One of the current applications of indocyanine green (ICG) is colorectal surgery, and with this, we evaluate our initial experience in colonic resections using NIR fluorescence.

Materials and Methods: 141 patients who underwent complex laparoscopic colonic surgeries (right hemicolectomies n = 51, left hemicolectomies n = 81, transverse resections n = 7, right colectomy with sigmoid segmental resections = 2) between 2017 and 2021 were included. Intravenous injection of ICG was administered before stapling the colon and after performing the anastomosis under NIR visual control. A retrospective analysis of the patients treated in our hospital using this technique was performed, and data about how ICG influenced the intraoperative decisional process and anastomotic site complications were collected.

Results: The primary aim was to assess whether ICG angiography could lead to a further bowel resection. ICG angiography demonstrated improper perfusion of the colic stump, which led to extended bowel resection in 7 cases (4.96%). An anastomotic leak developed in 2 patients (1.41%)

Conclusions: Intraoperative ICG angiography can be a proper tool for evaluating the colic partners' vascularization and the performed anastomosis in patients undergoing colonic resection.

COLORECTAL—Benign

O150—Laparoscopic Lavage for Complicated Appendicitis, Shall We Leave a Drain?

Julio Gavilán Parras ¹ , R. Escalera-Pérez¹, S. MacMathuna¹, D. Raposo-Puglia¹, S. Martín-Arroyo¹

¹Jerez de la Frontera University Hospital, General Surgery, Spain

Aim: The morbidity associated to acute appendicitis, depends highly on the stage of evolution. Traditionally, leaving a drain after a complicated appendectomy used to be the standard. However, current WSES guidelines discourage this action (Strength of recommendation 1B). Therefore, we evaluated in our health district whether laparoscopic lavage is enough for complicated appendicitis, or if leaving a drain really reduces postoperative complications.

Methods: We have performed a cohort study including all complicated appendectomies performed laparoscopically in Jerez de la Frontera University Hospital in 2021. We excluded those uncomplicated, planned for open surgery or which required conversion. The variables studied were: Length of stay, need of antibiotics, reintervention, appearance of postoperative complications and Clavien-Dindo Score. Statistical analysis was performed using SPSS version 22.

Results: In 2021 we performed 42 complicated appendectomies laparoscopically. A drain was used in 24 (57,1%) patients. The drain cohort had a mean stay of 6.6 (SD 4.4) days, whereas the mean in the cohort without the drain was 3.9 (SD 2.4) days (Student´s t P = 0.023). Antibiotics after discharge were used in 21 (87.5%) patients in the group with the drain, and in 11 (61.1%) in the group without it (Chi-square P = 0.047). Only one patient (4.2%) required reintervention in the group with the drain, while as three (16,7%) required it in the group without a drain (P = 0.17). In the drain cohort 5 (20.8%) patients suffered from any postoperative complication (chart 1), whereas 7 (38.9%) had a complication in the cohort without it (P = 0.2). In the drain group Clavien-Dindo scores were II in 21 (95.6%) patient with only one scoring IV; in the group without the drain: three (16.7%) scored I, 12 (66,7%) scored II and three (16.7%) scored III (P = 0.02) (chart 2).

Conclusion: The use of surgical drains may be related to longer postoperative stay, however this study showed better postoperative outcomes in the group that used them. This results, which oppose the current guidelines, could be related to the small size of our sample. For this reason, further analysis will be needed to evaluate how the use of drains influences postoperative results.

COLORECTAL—Benign

O151—Effectiveness of Indocyanine Green-Guided Visualization of Ureter during Laparoscopic Surgery for complicated Chronic Diverticulitis

Francesco Pietro Maria Roscio ¹, F. Clerici¹, F.M. Carrano¹, A. Calori², I. Scandroglio¹

¹ASST Valle Olona, General and Minimally Invasive Surgery, Italy, ²ASST Valle Olona, Urology, Italy

Aim: To evaluate the effectiveness of ureteral visualization by placement of stent subsequently instilled with indocyanine green (ICG) in order to prevent iatrogenic ureteral injuries (IUI) during laparoscopic left colectomy for chronic diverticulitis complicated by pseudotumor.

Methods: A consecutive unselected series of 8 patients undergone elective surgery for chronic diverticulitis complicated by pseudotumor at pre-operative CT-scan in 2021 was retrospectively evaluate. All patients were treated by pure 4-ports laparoscopic left colectomy with preoperative placement of monolateral or bilateral 6-Fr open-ended ureteral stents. Stents were instilled with ICG 2.5 mg in saline 5 ml (Verdye, Diagnostic Green GmbH, DE), then clamped and checked by near-infrared fluorescence imaging system (Karl Storz SE & Co, Tuttlingen, DE). We routinely used the same technology to evaluate visceral perfusion before fashioning anastomosis. All the procedures were performed by the same team. Perioperative care plan, operative steps and surgical instrumentations were standardized. We collected patients-, surgery- and hospital stay–related data, as well as short-term outcomes. Complications were classified using the Clavien–Dindo classification system (CDCS).

Results: There were 3 men (37.5%) and 5 women (62.5%) with a mean age of 63.0 ± 10.7 years. The mean body mass index was 27.8 ± 3.8 kg/m2. Previous uncomplicated diverticulitis rate was 3.3 ± 0.9. No conversion to open surgery was registered. In 6 patients (75%) a unilateral ureteral stent was placed, in 2 (25%) bilateral. Timing for placement and intraoperative clamping of the stent were 16.2 ± 5.8 and 67.5 ± 15.6 min, respectively. The mean operative time and estimated blood loss were 216.2 ± 31.6 min and 131.2 ± 84.2 ml respectively. All the specimens showed diverticulitis and peridiverticulitis with associated inflammatory pseudotumor. Length of hospital stay was 8.5 ± 1.6 days and we have not recorded any readmissions in patients discharged within 60 days after surgery. Complications rate was 25% for grade 2, while no one of grades 3 or higher according to the CDCS were registered.

Conclusions: ICG-guided visualization of the ureter has been shown to be an effective tool for minimizing IUI during laparoscopic surgery for complicated chronic diverticulitis.

COLORECTAL—IBD

O152—Laparoscopic Technique in the Treatment of the Ulcerative Colitis Associated Colorectal Carcinoma

Janos Tajti Jr ¹ , S. Ábrahám¹, Z. Simonka¹, A. Paszt¹, G. Lázár¹

¹Szent-Györgyi Albert Health Centre, Surgery, Hungary

Aims: Ulcerative colitis (UC) associated colon tumor is a rare entity. It forms only 2% of the colorectal cancers, however it is the cause of death in 15% of the patients with UC. The cummulative probability of UC patients developing colorectal carcinoma is 2% by 10 years, 8% by 20 years and 18% by 30 years. The objective of the study is to investigate the appearance of UC associated colorectal cancer in our UC population.

Methods: Between 1 January 2003 and 01 October 2021, surgery was performed for UC associated colorectal carcinoma in 22 patients. The mean age of the patients was 56 years. There was an average 22 years from diagnosing the disease to surgery. Eighteen cases were elective interventions, while 4 were emergency surgery. Three patients did not attend gastroenterological follow-up for decades.

Results: Preoperative colonoscopy showed inflammation in 2 cases, high grade dysplasia in 3 cases, while UC associated carcinoma was described in 11 patients in the rectum and sigmoid colon, in 1-1 patient in the coecum or transversum and in 3 patients in the splenic flexure. Only palliative stomas were performed in the emergency cases, and colectomy/proctocolectomy were carried out during the elective surgeries. There were no postoperative mortality. Postoperative histology revealed high tumor stages (T2-T4) in 18 cases. 69% of the patients had positive locoregional lymph nodes and distant metastasis like liver, lung, urinary bladder, peritoneum.

Conclusion: Considerable proportion of cases with UC associated colorectal carcinoma had undergone surgery in advanced tumor stages. The mean age of these patients were lower than in patient with sporadic colon carcinoma. UC population needs regular gastroenterological surveillance. Minimally invasive procedures can be used safely for the surgical treatment of UC associated colon tumors.

COLORECTAL—Malignant

O153—“Total Neoadjuvant Therapy” in Locally Advanced Rectal Cancer Patients. Preliminary results

Andrea Picchetto ¹ , F. De Felice², F. Iafrate², E. De Stefani³, S. Magaletti³, A. Gelibter⁴, F.M. Magliocca⁵, D. Musio², S. Caponetto⁴, G. Casella⁶, I. Clementi⁶, G. Sirgiovanni⁷, M. Parisi⁸, C. Orciuoli⁷, G. Torrese⁸, G. De Toma⁶, V. Tombolini⁸, E. Cortesi⁷, G. D'Ambrosio⁹

¹Sapienza University of Rome, Policlinico Umberto I University Hospital, Emergency-Acceptance, Critical Areas and Trauma Department, Italy, ²"Umberto I" University Hospital, "Sapienza" University of Rome, Department of Radiotherapy, Italy, ³"Umberto I" University Hospital, "Sapienza" University of Rome, Department of General Surgery and Surgical Specialties, Italy, ⁴"Umberto I" University Hospital, "Sapienza" University of Rome, Medical Oncology Department, Italy,⁵Sapienza University of Rome, Policlinico Umberto I University Hospital, Department of Radiological Sciences, Oncology and Pathology, Italy, ⁶Sapienza University of Rome, Policlinico Umberto I University Hospital, Department of General Surgery, Italy, ⁷Sapienza University of Rome, Policlinico Umberto I University Hospital, Medical Oncology Department, Italy, ⁸Sapienza University of Rome, Policlinico Umberto I University Hospital, Department of Radiotherapy, Italy, ⁹Sapienza University of Rome, Policlinico Umberto I University Hospital, Department of General Surgery and Surgical Specialties, Italy

Aims: The use of neoadjuvant chemoradiotherapy nChRT in locally advanced rectal cancer can lead to tumor downstaging and downsizing in about 85% of cases and complete response in about 15% of cases (yT0N0). The purpose of this study is to evaluate the efficacy and safety of the so-called “Intensified total neoadjuvant therapy plus targeted agent (TA)“ which involves the use of induction chemotherapy (IC) with FOLFOXIRI + TA (such as bevacizumab or panitumumab-cetuximab), followed by intensified nChRt and followed again by surgery at 10-12 weeks after nChRT in patients with locally advanced rectal cancer (LARC).

Methods: The study is of a single-center, prospective type. The sample examined consisted of 26 patients with LARC (cT3-4, N ±) who underwent (and completed) the “Intensified total neoadjuvant therapy plus TA” therapeutic scheme. Based on Ras-BRAF status, patients were treated with FOLFOXIRI with the addition of bevacizumab (Ras-BRAF mutation) or panitumumab-cetuximab (WILD-TYPE Ras BRAF), followed by nChRT (50.4 Gy with oxaliplatin- 5-fluorouracil) and surgery 10-12 weeks after the end of radiochemotherapy treatment. The ultimate aim was to evaluate the complete tumor remission, downstaging and downsizing rates. Clinical (c Stage), post IC (y Stage), post nChRT (yy Stage) and histopathological (yp Stage) staging were also evaluated.

Results: FOLFOXIRI plus bevacizumab was administered in 11 mutated Ras-BRAF patients, whereas the 17 wild-type Ras-BRAF patients received FOLFOXRI plus panitumumab/cetuximab. All but one of the 26 patients (96,15%) achieved tumor downstaging/downsizing. Complete response was achieved in 9 cases (32,1%) and a ypT1 ypN0 was achieved in 2 patients (7,2%). In patients undergoing surgery, the resection was radical (R0) in all the cases. About the 9 patients with complete response (CR), 3 pts underwent the “watch and wait” protocol and did not show disease recovery (F-Up 8 months). In the 6 patients with CR who underwent resection, the histological examination confirmed the complete pathological response (yypT0N0).

Conclusions: The therapeutic protocol with induction chemotherapy plus targeted agent and intensified ChRT in patients with locally advanced rectal cancer showed, in a pilot sample of 26 patients, a complete response in 32,1% of cases. Patients are being enrolled to confirm the results in a wider and adequate follow-up series.

COLORECTAL—Malignant

O155—Open vs Laparoscopic Right Hemicolectomy with Complete Mesocolic Excision and Central Lymphadenectomy for Right Colon Cancer. A Prospective Randomized Study

Mohamed El Sorogy ¹ , A. El Nakeeb¹, E. Atef¹, A. El Hawary¹

¹Gastrointestinal Surgery Center, Mansoura University, Surgery, Egypt

Aim: The aim of this is to evaluate the safety, efficacy, and short-term oncologic outcomes of laparoscopic right hemicolectomy with complete mesocolic excision (CME) with central vascular ligation (CVL) for right colon cancers compared with open surgery.

Methods: This is a prospective randomized study on patients with right colonic cancer from July 2017 to January 2019 to be managed in Gastrointestinal Surgical Center, Mansoura University, Egypt. Patients were divided into two groups (open and laparoscopic) by closed envelope method. Patients with distant metastasis or large tumors (> 7cms) were excluded. Right hemicolectomy with CME and CVL was done in all cases. Institutional Review board approval was obtained.

Results: 66 patients were included in the study (33 patients in each group). Both groups were comparable regarding patients demographics. Operative time was significantly longer in the laparoscopic group (p = 0.001). Analysis of the operative variables are shown in Table 1. The incidence of post operative complications was similar in both groups (Table 2). Laparoscopic group patients resumed oral intake earlier and had a shorter hospital stay. The number of LNs harvested was similar in both groups (20 vs 21, laparoscopic vs open groups, P = 0.86)

Conclusions: Laparoscopic right hemicolectomy with CME for right colon cancer is feasible, safe and effective with oncological outcomes mostly similar to those of open surgery.

Table 1

		Median		P
		Open (N = 33)	Laparoscopic (N = 33)
Type of anastomosis	End to end	21 (63.6%)	6 (18.2%)	0.001
	Side to side	11 (33.4%)	24 (72.7%)
	End to side	1 (3%)	3 (9%)
Stapler		0 (0%)	24 (72.7%)	< 0.0001
Suture material	Vicryl 3/0	29 (87.8%)	33 (100%)	0.119
	PDS 3/0	3 (9%)	0 (0%)
	SILK 2/0	1 (3%)	0 (0%)
Method of dissection	Harmonic	0 (0%)	33 (100%)	< 0.0001
	diathermy	33 (100%)	0 (0%)
Covering ileostomy		1 (3%)	0 (0%)	1
Blood loss (ml)		200 (50–420)	210 (100–540)	0.985
operative time (min)		150 (70–240)	180 (135–240)	0.001
Time of dissection (min)		110 (30–145)	110 (80–180)	< 0.001
Time of anastomosis (min)		30 (25–60)	35 (20–60)	0.339

Table 2

	Operation		P value
	Open (N = 33)	Laparoscopic (N = 33)
Post-operative leakage	3 (9%)	2 (6%)	1
Post-operative bleeding	1 (3%)	0 (0%)	1
Post-operative wound infection	1 (3%)	3 (9%)	0.613
Intra-abdominal infection	1 (3%)	0 (0%)	1
Day of first motion)day)	3 (2–7)	2 (1–4)	< 0.001
Start oral intake)day)	4 (3–8)	3 (2–4)	< 0.001
Hospital stay)day)	6 (4–41)	5 (4–8)	0.002

COLORECTAL—Malignant

O158—Surgical Outcomes of Colonic Tumours in Our Institution

Mohamed Salama ¹, W. Shabo¹, F. Kazi², B. Sami¹, A.R. Nasr¹, I. Ahmed¹

¹Our Lady of Lourdes Hospital, General Surgery, Ireland, ²NUI Galway, General Surgery, Ireland

Introduction: Colorectal cancer (CRC) is one of the most common cancers worldwide. The incidence of CRC has increased in the last decades. Its incidence changes over time and varies regionally. Currently incidence rates are declining in the elderly but are increasing in young adults. Age related disparities in CRC incidence, biological behaviour, treatment, and recurrence rate exist with great volume of controversy regarding clinical outcome of young patients diagnosed with CRC when compared with older counterparts.

Aims: To evaluate and assess CRC in our units comparing outcomes in different age groups and focusing on the different stages at presentations, locations, and management.

Methods: All patients diagnosed with CRC in our hospital from 2012 to 2018 were included and classified into three age groups. Group 1: Less than 50 yr, Group 2: 50-75 yr, Group 3: Above 75 yr. Data collected: Age, Sex, Location of tumour, Characteristic of tumour, Treatment: Surgical (Curative/Palliative, Emergency/Elective); Non-surgical and Outcome (morbidity/mortality). 43 anorectal cancers excluded as they were operated in a different hospital

Results: Total number: 342 (F:141, M:201), age range: 30-96y. Group 1: 29 (F:7, M:22), Group 2: 177 (F:65, M:112), Group 3: 136 (F:51, M:85). Tumour Location: Left: 166, Right: 176 4 patients underwent palliative treatment (3 advanced stage, 1 elderly). 29 patients (8.5%) underwent emergency surgery secondary to obstruction or perforation. (F: 14, M: 15) Age range: 41-93y. With respect to tumour stage, 93% of Group 1, 91% of Group 2 and 86% of Group 3 presented with stage 3 or more. Regarding the mortality: Follow-up showed that 87 out of 342[F:31 (35.6%), M:56 (64.4%)] died with a mortality rate of 25.4%. Mortality in age group 1 was 3(10.3%), group 2 was 48(27.1%) and group 3 was 36(26.4%).

Conclusions: CRC can occur at any age. Increased CRC in younger age group is observed in Irish population. Symptomatic young patients should get appropriate investigations. Family physicians should never dismiss warning symptoms. Educational campaigns are needed to alert clinicians about early onset CRC. Chronic age is no longer a barrier to individualise treatment.

ROBOTICS & NEW TECHNIQUES—Bariatrics

O159—Totally Robotic SADI-S—Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy for Superobese Patients

Ricardo Zorron ¹ , W. Eskander¹, M. Specht¹, C. Grande¹

¹Klinikum Ernst von Bergmann Potsdam, Center for Bariatric and Metabolic Surgery, Germany

Background: Patients with super-superobesity are of difficult primary bariatric management. Issues regarding exposure and technical difficult anastomosis sometimes led to the choice of a 2-stage procedure.

Objectives: Robotic SADI-S procedure may allow safe surgery by overcoming technical issues in patients with BMI > 50 kg/m2, as a revisional or primary procedure.

Methods: Patients with BMI over 50 kg/m2 without reflux symptomatic were scheduled for robotic SADI-S procedure, and the results compared to our series on laparoscopic SADI for the same indications. The video describes key issues to perform this technique safely. 1. Position supine, six trocars are inserted, Da Vinci arms are docked to the left shoulder of the patient. 2. The omentum is separated from the greater curvature close to the stomach using DaVinci sealer and sleeve gastrectomy is performed. 3. The duodenum is stapled. 4. The small bowel loop for the anastomosis is identified going backwards 300 cm from the ileocecal junction. 5. Anastomosis is performed in a 2-row fashion or using linear stapler. Differences and key points of the robotic technique are compared to the laparoscopic SADI technique.

Results: Totally robotic SADI-S was performed in this selected group of patients and the technical issues were identified. The anastomosis is performed using a two-layer hand-sewing suture. Operative time (mean 138 min) is not extended compared to laparoscopic procedure (mean 144 min). Complication rate was low for the two groups, mean postoperative stay was a mean of 3 days.

Conclusions: This new technique is a promising option to provide effective therapy for obesity patients classified as superobese. Besides the operative times, there was no differences in performance of robotic SADI-S in one or two step procedure. The indication for a 2-step strategy should be based on the technical complexity and clinical status of the patient.

BARIATRICS—Endoluminal

O160—Hybrid Technique of Restrictive Bariatric Operations

A. Reiti¹, Andrii Kurmanskyi ¹, D. Tsyhyka², O. Shcherbina³, V. Hordovskyi¹, V. Tertychna³

¹National Healthcare University of Ukraine, Surgery and Proctology, Ukraine, ²Uzhgorod Regional Oncology Hospital, Surgery, Ukraine, ³Kyiv Clinical Hospital No 7, Mini Invasive Surgery, Ukraine

Purpose/Background: The number of obese and overweight patients is growing quickly. Endoscopic gastric volume reduction is one of the best solution to obese patients but not for overweight. Gastric sleeve is the most frequently performed bariatric surgery in the world and has earned the trust of doctors for its high safety and effectiveness in the treatment of obesity. Endoscopic gastric volume reduction method is greatly hampered by its high cost and difficulties in using the equipment. The proposed method of hybrid transluminal laparoscopic gastroplasty demonstrates its effectiveness in terms of weight loss, technical accessibility, economic feasibility in use.

Aim: The aim of the method is to determine the technical feasibility of using endoluminal gastric volume reduction and to analyze early postoperative complications and efficacy in comparison with sleeve gastrectomy.

Methods/Intervention: There were 2 groups: control (laparoscopic sleeve resection) and experimental (transluminal laparoscopic gastroplication). The average weight was 116.5 + -5.1 kg. Endotracheal anesthesia was used. In the control group, a standard sleeve resection was performed through 5 ports using 60, 45 and 30 mm Covidien Endo GIA cassettes in black, purple and blue. In the experimental group, 10 mm optics and two 5 mm troacars entered the abdominal cavity. These two 5 mm trocars were inserted into the stomach under endoscope control. Preliminarily, a temporary clip was placed on the small intestine under the Treitz ligament. After the trocars were inserted into the stomach, the abdominal cavity was desuflated and manipulations were performed into the stomach. The twisted suture V lock 2.0-40 cv on a calibration probe (we used a gastroscope as a probe) sutured the stomach from the gastroesophageal junction to the pyloric part of the stomach. After that the trocar holes were sutured with interrupted sutures.

Results: No early complications such as bleeding or perforation, or failure of gastric sutures were observed in both groups. One month later, during the control gastroscopy in the experimental group, the eruption of the lower third of the suture was observed in 1 study animal—the results of changes in body weight were not taken into account. In the experimental group, the amount of food consumed decreased by an average of 24.7 + -2.2% ( control group 61.2 + -5.1%). The average weight loss per month in an experimental group was 5.4 +—0.73 kg (control group 10.4 + -1.1 kg).

Fig. 1 Significantly less weight loss in the experimental group compared to the control

Fig. 2 The average weight loss per month in a control group and experimental group

Strong direct correlation between decreased food intake and weight loss. (r = 0.84 p < 0.01). The average weight before operation was 116.5 + -5.4 kg. and after operation was 109.2 + -5.0 kg in experimental group and 105.1 + -4.8 kg. in control group. Statistically significant weight loss (p < 0.05).

Limitations: This is an animal model that does not show immediate results in obese patients, remote results data are also needed.

Conclusion: the method has shown encouraging results: Its main advantage is that it does not need special equipment and can be applied in any hospital, the method does not alter the primary anatomical configuration of the stomach at all (it does not require mobilization of a large curvature, removal of a part of the stomach or irreversible gastric plication), the method is easily reproducible and does not require a long learning curve. The method is suitable for patients with BMI 30-35 kg/m2. Standard sleeve resection and endoscopic sleeve demonstrates more convincing results in weight loss, as well as much higher expenditure on consumables.

ROBOTICS & NEW TECHNIQUES—Bariatrics

O161—Sleeve Gastrectomy with Anterior Dor 180° Fundoplication (D-SLEEVE) for Obesity with Symptomatic Gastroesophageal Reflux: Results of First Series

Ricardo Zorron ¹ , W. Eskander¹, M. Specht¹, C. Grande¹

¹Klinikum Ernst von Bergmann Potsdam, Center for Bariatric and Metabolic Surgery, Germany

Background: Sleeve gastrectomy (SG) is currently the most performed bariatric surgery worldwide. For patients with obesity and symptomatic gastroesophageal reflux disease (GERD), sleeve gastrectomy is usually contraindicated due to the possibility of worsening or de novo reflux in the postoperative follow up. A new method, the combination of a 180 degree anterior fundoplication (D-SLEEVE) using only one barbed non-absorbable suture is proposed to allow the use of SG for this set of patients.

Aim: Evaluated the safety, feasibility and efficacy of sleeve gastrectomy with anterior 180 degree fundoplication (D-SLEEVE) for the therapy of morbidly obese patients with preoperative symptomatic GERD.

Methods: The study describes the first series of robotic and laparoscopic D-SLEEVE performed in Germany. Between June 2018 to July 2020, patients were selected when they complained of severe reflux before procedure and have the proton pump inhibitor (PPI) therapy for the symptomatic reflux at least 6 months before surgery. All operations were performed via the laparoscopic platform. Clinical data were collected from our Bariatric Center database at Potsdam-Germany. The primary outcomes included technical success, perioperative complications and mortality, and the resolution of the symptomatic gastroesophageal reflux after D-SLEEVE procedure.

Results: The D-SLEEVE procedures have been successfully performed for all patients (n = 69). Mean operative time was 77 min. All patients started oral fluids an hour after the surgery, and were discharged on postoperative 2 or 3 days, without postoperative complications. Three patients claimed of intractable reflux after 6 months and was converted to the Roux-en-Y gastric bypass. The remaining patients (n = 66) experienced complete resolution of reflux symptoms in 6-month follow-up. The %Excess Weight Loss (%EWL) was 50.1% on postoperative 6 months.

Conclusions: D-SLEEVE with one barbed suture is a safe, effective, and quick alternative technique to allow the performance of sleeve gastrectomy for morbidly obese patients with preoperative symptomatic gastroesophageal reflux, especially for patients with super obesity as the first step operation.

BARIATRICS—Laparoscopic

O163—Early experience with Single Anastomosis Duodeno-Ileal bypass with Sleeve Gastrectomy (SADI-S)

Andrei Keidar ¹ , I. Carmeli¹, N. Nevo¹

¹Assuta Ashdod Hospital, Surgery, Israel

Background: SADI-S has been described in 2007 as a simplified modification of the classic Biliopancreatic Diversion with Duodenal switch Suggested to result in similar weight lost and co-morbidities improvement with less long term nutritional complications.

Methods: A retrospective analysis of a prospective collected data-base on all consecutive SADI-S procedures done at A university Public Hospital between August 2018 To March 2021.

Results: Fifty five patients underwent SADI-S as primary o procedure or conversion due to weight lost failure or weight regain. 30 were Female, Average age, weight and BMI at the time of surgery was 36 years, 123 kg and 44.5 kg/m2, respectively. Twenty five patients were converted from another Bariatric procedure: 17 from Sleeve, 3 adjustable bands and 5 from Roux-en-Y Gastric Bypass. All procedures were completed laparoscopically by one of two Bariatric Surgeons. Mean operative time was 145 min and average length of stay was 3.2 days. There was two major complication, Sleeve staple line leakage which was treated by endoscopic stent placement, one bleeding and two minor complications of Surgical site infections. There was no mortality and none complications related to the anastomosis were noted. One year follow up data was available in six patients in whom %EWL was 100% (81-128%). Nutritional deficiencies were observed in two patients, one with Anemia and one with Osteoporosis as average Hemoglobin level were 12.8 g/dL (11.3-14.5), B12 500 pmol/L and all fat soluble vitamins were at normal levels other than vitamin D.

Discussion: At 1 year of follow up this small cohort suggest the potential of SADI-S to be a very effective bariatric procedure with acceptable preoperative complications and Nutritional deficiencies.

Conclusions: Our preliminary data support that SADI-S is a powerful bariatric procedure for carefully selected patients.

BARIATRICS—Laparoscopic

O164—Indocyanine Green Fluorescence Angiography During Laparoscopic Bariatric Surgery: A Pilot Study

Andrea Balla ¹ , D. Corallino¹, L. Palmieri¹, F. Meoli¹, I. Cordova Herencia¹, S. Quaresima¹, A. Paganini¹

¹Sapienza University of Rome, Department of General Surgery and Surgical Specialties “Paride Stefanini”, Italy

Aims: Indocyanine green (ICG) fluorescence angiography (FA) is used in surgery for several purposes, but its use in bariatric surgery is still debated. Aim of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery as a predictor of ischemic leak risk.

Methods: Eleven patients underwent bariatric surgery with ICG-FA. Patients’ characteristics are shown in Table 1. Three mL of ICG diluted with sterile water was injected intravenously after gastric tube creation during laparoscopic sleeve gastrectomy and after the gastric pouch creation and anastomosis during laparoscopic gastric by-pass. For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest was used to identify the vascular supply. The perfusion pattern was assessed according to a visual analog scale (VAS), assigning a score from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures.

Results: No adverse effects to ICG were observed in this series. In 9 patients (81.8%) ICG-FA score was 5. During two laparoscopic re-do gastric by-pass procedures, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (18.2%). Leaks were not observed at a median follow-up of 4 months.

Conclusions: ICG-FA during bariatric surgery is a safe and feasible technique. Its use could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger number of patients are required to draw definitive conclusions.

HEPATO-BILIAIRY & PANCREAS—Pancreas

O165—“Cold Triangle Robotic Pancreatoduodenectomy”: Technique, Postoperative Complications and Pathological Results

Emanuele Federico Kauffmann ¹ , N. Napoli¹, M. Ginesini¹, G. Cesare¹, A. Salamone¹, F. Vagelli¹, F. Vistoli¹, U. Boggi¹

¹Università di Pisa, Department of General and Transplantation Surgery, Italy

Background: In pancreatoduodenectomy (PD) for pancreatic cancer the triangle procedure improves the rate of negative margin resections. The R0 resection is crucial to improve the prognosis. The clearance of the perineural tissue along the peripancreatic arteries could be challenging and performed with sharp dissection or with the help of energy devices. Sharp clearance of all soft tissue included in the space lined by the common hepatic artery/celiac trunk, the superior mesenteric artery (SMA), and the superior mesenteric/portal vein (triangle operation) may improve the rate of negative margin resection in pancreatoduodenectomy for pancreatic cancer. We herein present the technique of “cold” triangle robotic pancreaticoduodenectomy

Methods: Basically, a radical and en-bloc clearance of the mesopancreas should be performed by a four-step procedure. Dissection is carried out using only robotic scissors. During the first step perivascular triangle dissection begins with division of the gastroduodenal artery and lateral-to-medial dissection along the hepatic artery, then along the right side of the celiac trunk until the diaphragmatic crus. In the second step, after a wide Kocher maneuver, the origin of the SMA and the celiac trunk are identified, cranial to the left renal vein. The lymphatic tissue above the left renal vein and the right ganglion are removed en-bloc with the specimen. In the third step the peritoneum behind the third duodenal portion is opened. The first jejunal loop is mobilized to the right side of the mesenteric vessels and finally divided. During the fourth step, the divestment of the SMA proceeds until the inferior pancreato-duodenal artery is visualized and ligated. The divestment is performed without energy devices to reduce the risk of diathermic injury and late bleeding. Usually, a right approach is employed with a bottom-to-up dissection. The Clavien-Dindo classification was used to grade the severity of post-operative complications. Post-pancreatectomy hemorrhage (PPH) delayed gastric emptying (DGE), chylous fistula were classified accordingly to ISGPS criteria and collected as ideally associated with the surgical technique. In this analysis we considered patients from August 2009 to September 2021 underwent robot-assisted PD for pancreatic cancer.

Results: This technique was developed in 252 procedures and was employed in 127 RPDs for pancreatic cancer. The median operative time was 540 (470-585) minutes. No conversion occurred due to troublesome dissection or bleeding. Reoperation was needed in 14 patients (9.4%), out of these 11 (8.6%) were for bleeding, one (0.8%) for intestinal volvulus, 2 (1.6%) for fluid collections not amenable of percutaneous drainage. No pseudoaneurysm of the gastroduodenal artery was observed, one patient was reoperated for bleeding and only one case (0.8%) of erosive bleeding from the superior mesenteric artery probably due to thermal injury was reported. The chyle leak rate was 3.2%. The mortality, excluding the first 33 patients of the population to complete the learning curve, was 5/219 (2.3%). The rate of R1 resection (circumferential margins at 1 mm) was 44.1%. The median number of examined lymph nodes was 42 (33-51).

Conclusions: “Cold” Triangle RPD allows to achieve satisfactory pathology parameters with a acceptable risk of post-pancreatectomy surgical complication.

HEPATO-BILIAIRY & PANCREAS—Pancreas

O166—Assessing Outcomes Of Robotic Pancreatoduodenectomy According to the Open Pancreatoduodenectomy Benchmark Cutoffs: An International Multicenter Cohort Study

Leia Jones ¹

¹AmsterdamUMC, Surgery, The Netherlands

Introduction: Robotic pancreatoduodenectomy (RPD) is shown to be safe and feasible in experienced high-volume centers. With the lack of randomized trials comparing RPD with open pancreatoduodenectomy (OPD), evidence on the benefits of RPD is limited to retrospective series, prone to treatment allocation bias. Recently, outcome benchmarks for OPD were established to enhance unbiased outcome comparisons. This study aimed to compare international RPD outcomes to OPD benchmarks cutoffs.

Methods: An international multicenter retrospective cohort study, including consecutive RPD cases from high-volume centers (first case—31 December 2019) was conducted. Outcomes were compared to OPD benchmark cutoffs, reported by Sánchez-Velázquez et al., in subgroups; the benchmark cases (low-risk patients), patients with ASA ≥ 3, BMI ≥ 30 kg/m², PDAC and aged ≥ 75 years. Outcomes after portomesenteric venous resection (PVR) were compared to OPD benchmark cutoffs, reported by Raptis et al.

Results: Overall, 2186 RPD cases from 18 centers in 8 countries were included, with median annual volume of 24. The percentage of benchmark cases was 53.5% (n = 1169). The subgroup RPD-benchmark cases showed following outcomes compared to the OPD benchmark cutoffs: operative time (5.5 vs 7.5 h), post-operative pancreatic fistula grade B/C (CR-POPF) rate (13.6% vs 19%), Clavien-Dindo grade ≥ 3 rate (14.4% vs 30%), in-hospital or 30-day mortality (1.1% vs 1.6%) and R1 rate for PDAC (12.4% vs 39%). The subgroup analysis of RPD with PVR showed following outcomes compared to open benchmark cutoffs for PVR (7.5 vs 8 h, 7.3% vs 14%, 14.5% vs 34%, 2.4% vs 4% and 35.8% vs 63%) respectively.

Conclusions: Outcomes of subgroups RPD-benchmark cases, ASA ≥ 3, PDAC, aged ≥ 75 years meet the established OPD benchmark cutoffs for the following intra/post-operative outcomes: Clavien-Dindo grade ≥ 3 rate, CR-POPF, severe postoperative bleeding and R1 rate. RPD-benchmark cases and patients with PVR meet the benchmark cutoffs for in-hospital or 30-day mortality rate. Future multicenter matched studies are needed to assess and compare outcomes of RPD versus OPD in high-risk patient groups.

ROBOTICS & NEW TECHNIQUES—Pancreas

O168—Occurrence of Delayed Gastric Emptying After Pylorus Preserving Pancreatoduodenectomy: A Comparison Between the Robotic and the Traditional Open Approach

L. Morelli¹, Cristina Carpenito ¹ , M. Palmeri¹, G. Di Franco¹, N. Furbetta¹, S. Guadagni¹, A. Comandatore¹, C. Carpenito¹, C. Gianfaldoni¹, M. Mastrangelo¹, A. Di Dato¹, G. Di Candio¹

¹University of Pisa, General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, Italy

Aims: Delayed gastric emptying (DGE) is one of the most frequent complications after pancreaticoduodenectomy, with a reported incidence of up to 61%. DGE is associated with prolonged hospital stay, increased costs, reduced quality of life and need of parenteral or enteral feeding. Robotic pancreaticoduodenectomy (RPD) has been proved to be safe, technically feasible and associated with some advantages compared to the traditional open approach (OPD). Our aim is to evaluate the impact of a fully robotic approach on the occurrence of DGE following pancreaticoduodenectomy.

Methods: Delayed gastric emptying (DGE) was defined according to the International Study Group of Pancreatic Surgery (ISGPS) as the requirement or re-insertion of a nasogastric tube (NGT) after postoperative day (POD) 3 or failure to start oral diet by POD 7, and further subdivided into grade A, B or C in order of increasing severity. A clinically relevant DGE was defined as a DGE grade B or C. From January 2009 to December 2021 385 patients underwent open or robotic PD. RPD group is composed by 32 pylorus-preserving pancreaticoduodenectomy (PpPD) and only 8 Whipple’s operation (PrPD). Therefore, we compared the Robotic PpPD (R-RpPD) with the open PpPD (O-PrPD), selecting two comparable groups among all PrPD using a one-to-one case-control design according to sex, age and American Society of Anesthesiologists score. The incidence and severity of DGE between these two groups of patients were compared.

Results: A total of 60 patients were selected for the retrospective matched cohort study (30 for each group). A clinically relevant DGE was reported in a lower percentage of cases in the R-PrPD group: 3/30 cases (10%) versus 10/30 cases (33.3%), p = 0.028. No difference in terms of post-operative complications, incidence and grade of post-operative pancreatic fistula was reported between the two groups. The median length of hospital stay was significantly shorter in the R-PrPD group: 10 days versus 15 days, p = 0.013.

Conclusions: The use of robot is associated to a lower incidence of DGE after PrPD, probably due to the less traumatism of the minimally invasive approach. Moreover, the lower incidence of DGE could contribute to the shorter length of hospital stay of the RPD.

HEPATO-BILIAIRY & PANCREAS—Liver

O170—Comparative Outcomes of Robotic Liver Resection for Tumours Located in the Anterior Versus Postero-Superior Segments

C. Cutolo¹, Andrea Belli ¹ , R. Patrone¹, G. Pasta¹, V. Granata², F. Izzo¹

¹National Cancer Centre- G.Pascale, Hepatobiliary Surgery, Italy, ²National Cancer Centre- G.Pascale, Radiology, Italy

Aims: The aim of this study is to compare the outcomes of robotic hepatectomy for tumours located in the anterior versus postero-superior segments.

Methods: Clinico-pathological, intra-operative and post-operative outcomes of patients submitted to robotic hepatectomy between January 2017 and June 2021 were prospectively recorded in a dedicated database and analysed. Patients (tot: 111) were divided in two groups, A and PS respectively, according to tumour location (anterior vs postero-superior segments)

Results: The two groups were homogeneous and comparable. Group PS included 34 patients while Group A consisted of 77 patients. The two groups had similar operative time (188,382 versus 187.27, p: 0.933), intraoperative blood loss (127.794 versus 131.690, p: 0.911), length of postoperative stay (6.176 versus 6.818, p: 0.288), rate of Clavien Dindo > 2 complications (0.03% versus 0.05%, p: 1,00), although patients in group PS had a higher IWATE score (5,676 versus 4.129, p:0.00). All patients had an R0 resection.

Conclusions: Despite robotic resection of tumours located at postero-superior segments is more technically demanding, there were no differences in the intraoperative and short-term outcomes between the two groups. Therefore, even at the beginning of the learning curve robotic hepatectomy seems to have the potential to overcome the impact of tumour location by facilitating the resection off posteriorly located tumours without compromising surgical outcomes

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O172—Fundus-First Salvage Technique for the Difficult Laparoscopic Cholecystectomy

James Lucocq ¹, K. Khan², A. Sajid², S. Mahmud², A.H.M. Nassar²

¹Ninewells Hospital, Department of General Surgery, United Kingdom, ²Monklands Hospital, Department of General Surgery, United Kingdom

Introduction: Achieving the Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) facilitates safe dissection. The CVS cannot be achieved in approximately one in six cases and “salvage techniques” may be utilised. Salvage techniques aim to perform a complete cholecystectomy without risking bile duct injury, whilst minimising the risk of other complications. The present study aims to report the outcomes of fundus-first dissection and identify candidates for fundus-first.

Method: The senior author’s experience of cholecystectomy over 29 years (1992 to 2021) was evaluated for the utilisation of fundus-first dissection. The outcomes of this technique were reported. Multivariate logistic regressions were performed to identify variables associated with fundus-first dissection.

Results: Five-thousand nine-hundred and fifteen laparoscopic cholecystectomies were included (median age, 51 years; M:F, 1:3.8; median ASA, 2). Fundus-first dissection was performed in 179 patients (3.0%). In the fundus-first group, the CVS could not be identified in 95.0% (170/179) and 96.6% (173/176) were performed in difficult cholecystectomies (Nassar grades III–V). The rate of fundus-first dissection increased with operative difficulty (I = 0.2%; II = 0.2%; III = 1.7%; IV = 11.7%; V = 41.1%). No bile-duct injuries occurred in the fundus-first group and seven patients (3.9%) had a significant complication (Clavien-Dindo ≥ 3). Three patients (1.7%) required conversion-to-open and two patients (1.1%) a subtotal cholecystectomy. Multiple pre-operative and operative variables were positively associated with fundus-first dissection.

Conclusion: The morbidity following fundus-first cholecystectomy is low despite high operative difficulty. In most cases, fundus-first dissection achieves complete cholecystectomy without the need for conversion-to-open, reducing peri-operative morbidity.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O173—Subtotal Cholecystectomy Versus Total Cholecystectomy in Complicated Cholecystitis

Volodymyr Grubnik ¹ , V. V. Grubnyk¹, K. Zahrebelna¹, V. V. Ilyashenko¹

¹Odessa National Medical University, Surgery, Ukraine

Introduction: In severe cholecystitis laparoscopic cholecystectomy (LC) can be technically difficult with a high risk of duct and arterial injury. To prevent injury, conversion to open cholecystectomy (OC) is usually made. Another solution is performing of laparoscopic subtotal cholecystectomy (LSTC). Aim of the study was to study the safety and complications of laparoscopic subtotal cholecystectomy (LSTC) compared to conversion to OC for technically difficult cholecystitis.

Methods: A retrospective review of 8764 LC performed from 2005 to 2020 in single center was done. In the 1st period, from 2005 to 2008, 2720 LC were performed. In technical difficulties conversion to OC was done. In the 2nd period, from 2009 to 2018, 4468 LC were performed. In technical difficulties LSTC was done.

Results: During the 1st period, there were 127 patients (4.7%) with technically difficult LC whom conversion to OC was done. Complication rate among these patients was 23%, bile duct injuries were detected in 3 patients (2.4%), mortality was 1.6%. During the 2nd period, there were 134 patients with technically difficult LC, thus LSTC was performed for 108 patients of them. Therefore, conversion to OC was made for the remaining 22 patients (0.6%). There were no bile duct injuries and no mortality in these patients. Complication rate after LSTC was 8.5%. Quality of life was assessed 6–48 months after surgery in 109 patients whom conversion to OC was done, and in 92 patients whom LSTC was done. Quality of life was better in patients after LSTC.

Conclusion: LSTC is good alternative to conversion to OC in complicated cases. It is good solution to prevent bile duct injury and save a principle of minimally invasive procedure in technically difficult LC, especially in high-risk patients.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O174—Benefits of Dual-Surgeon On-Call Team on Emergency Laparoscopic Cholecystectomy—A Single Centre Experience

C. Liao¹, Hazem Nasef ¹ , H. Nasef¹, A. Sivakkolunthu¹, N. Wong¹, B. Atkari¹

¹James Paget University NHS Foundation Trust, General Surgery, United Kingdom

Aims: Since 2015, UK national guideline has been to offer laparoscopic cholecystectomy for patients presenting with acute cholecystitis within 7 days of admission. The aim of this study was to measure the benefits of a second team of surgeons doing emergency operations (first team dealt with emergency admissions and referrals) in terms of morbidity, mortality, bile duct injury, length of stay and cost of readmission in a UK based district general hospital.

Methods: Retrospective analysis of a prospectively maintained database was compared with hospital episode statistics (HES) data, and any discrepancy in admission episode was resolved by reviewing contemporaneous electronic health records. Results were extracted in terms of admissions due to gallstone related disease. Number of index laparoscopic cholecystectomy, associated morbidity, mortality, bile duct injury, conversion to open, readmission rate, length of stay and cost of each readmission, compared over one year period, before and after the implementation of dual-surgeon on-call cover.

Results: In 2018, before implementation of dual-surgeon on call rota there were 847 gallstone related admissions, 324 cases were due to acute cholecystitis and 155 due to acute pancreatitis. Only 13 underwent laparoscopic cholecystectomy within 7 days of admission. The average length of stay (LOS) of those operated was 4 days, there was no mortality, bile duct injury or conversion to open in these patients. Average time from presentation till surgery was 108 days, with cost of each readmission on average £3072 per episode. In 2019, there were 909 gallstone related admission, of which 426 were due to acute cholecystitis and 183 due to acute pancreatitis. With dual-surgeon on-call cover, 114 patient underwent laparoscopic cholecystectomy within 7 days of presentation. Average LOS was 2.2 days, conversion to open was 4%, no bile duct injury but mortality was 1%. Average time from presentation to surgery was only 6.8 days. Average cost of readmission per episode was £1,551.

Conclusion: With adoption of dual-surgeon on call, early laparoscopic cholecystectomy benefits both patient and hospital. It reduces time to surgery for patients, decreases overall length of stay, and reduces readmission rates and cost, with similar morbidity and mortality.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

O175—Bile Duct Injuries During Laparoscopic Cholecystectomy—The Utility of ATOM Classification

Diana Schlanger ¹ , C. Popa¹, I. Cotaga¹, A. Ciocan¹, F. Graur¹, F. Zaharie¹, N. Al Hajjar¹

¹Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor, Surgery, Romania

Aims: Iatrogenic bile duct injuries are encountered in a small percentage during laparoscopic cholecystectomy, but they represent a significant problem that needs to be addressed correctly. Several classifications, like Strasberg, Bismuth, Hannover, etc. have been used to describe these lesions. Usually, it is recommended to refer such lesion to a specialized center for treatment, the results being better when the repairing surgeon is different from the injuring surgeon. Especially in this case, a comprehensive classification of the bile duct lesion is expected. The ATOM classification has been developed as an attempt for uniformization and it includes a comprehensive description: A (for anatomy), To (for time of), M (for mechanism).

Methods: Our study is a retrospective descriptive study that aims to identify the role of an uniform and comprehensive classification and its implication on the consecutive management of the bile duct injury. We have included patients diagnosed with bile duct injury after laparoscopic cholecystectomy, referred to our center, in a five-year period (2016-2020). The ATOM (anatomic, time of detection, mechanism) nominal EAES classification, as published in 2013, has been used.

Results: Sixty-two patients have been included in our study. Most of the bile duct injuries (71%) have not been classified before admission in our center, the rest of them (29%) have been described using the Strasberg classification. Out of the 18 patients that have been classified using the Strasberg system, in 55% (10 patients) the bile duct lesion could not be completely described by its assigned stage. About 21% of cases have been classified using ATOM classification at admission in our center. All cases have been retrospectively reclassified using the ATOM classification, at the time of this study. The ATOM stage has been corelated with the therapeutic conduit, with a concordance of more than 90%.

Conclusion: The ATOM classification has proven to be useful for a comprehensive description of the bile duct injury and subsequent guidance of the correct treatment according to the complexity of each lesion. A consistent classification should be adopted, in order to assure a uniform discussion on iatrogenic bile duct injuries.

UPPER GI—Reflux-Achalasia

O177—Endoscopic Anti-reflux Mucosectomy (ARMS) and Endoscopic Anti-reflux ablation (ARMA) as a Potential Treatment for Gastroesophageal Reflux-Single Center Experience

Tomasz Klimczak ¹

¹Gastroenteroterapia-Private Medical Clinic, Diagnostic and Interventional Endoscopy, Poland

Background: Gastroesophageal reflux (GERD) is one of the most common disorders of the alimentary tract. Apart from troublesome symptoms, untreated GERD can lead to Barrett’s esophagus and, as a consequence, esophageal adenocarcinoma. Up to date, most typical of GERD is PPI pharmacotherapy. However, in a number of cases this treatment is not sufficient or the patient does not tolerate PPI-group drugs. In these cases interventional therapy is recommended. Up to date, laparoscopic fundoplication ( Nissen, Toupet, Dor) was the only suggested option. Other, minimally-invasive procedures such as Stretta, MUSE, TIFF or EsophyX were not recommended due to the lack of clinical data. In 2014 professor H.Inoue from the Digestive Diseases Center, Showa University in Japan reported the first series of novel, endoscopic anti-reflux procedures: anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA).

Aim: The aim of our study was to asses the effectiveness of ARMS and ARMA procedures as a one-step treatment option for gastroesophageal reflux (GERD).

Materials and Methods: We conducted our prospective, single center study in 16 patients ( 9 female, 7 male) with PPI-refractory GERD. All patients underwent FSSG and GERD-HRQL evaluation and GE junction pressure study prior and 6 weeks after the procedures. ARMS procedures was conducted in cEMR technique and ARMA used argon plasma coagulation. After the procedure, all patients received per oral PPI treatment for 4 weeks.

Fig. 1 GE junction prior to ARMS

Fig. 2 GE junction after ARMS

Results: We successfully completed the procedures in all 16 patients. Mean procedure time was 42 min. No short-term nor long-term complications occurred. In 93,75% (15) of our patients achieved total, drug-free remission of GERD symptoms, FSSG scores < 3 and GERD-HRQL scores < 5. In one case, the patient had no GERD symptoms although still on PPI treatment.

Conclusions: The results of our study show that ARMS and ARMA are simple, safe, improve GERD-related symptoms and restore the GE junction’s anti-reflux capacity.

UPPER GI—Reflux-Achalasia

O179—The Role of the Angle of His in the Anti-reflux Mechanism of fundoplication

Main author: Gad Marom: Samer Michael ¹ , G. Marom¹, H. Al Haroob¹, R. Gefen¹, R. Brodie¹, Y. Mintz¹

¹Hadassah Ein Kerem, General Surgery, Israel

Introduction: Gastro-Esophageal Reflux Disease (GERD) is defined as pathological symptoms and complications resulting from reflux of gastric content into the esophagus. The natural anatomic anti-reflux mechanism, as well as the anti-reflux mechanism of anatomical fundoplication, are not well understood. Our aim was to study the role of the angle of His within the anti-reflux mechanism of fundoplication.

Methods: In this study, a total of 36 ex-vivo porcine stomachs were divided to 4 groups: control, myotomy only, myotomy and Nissen fundoplication and myotomy with Toupet fundoplication. Myotomy was performed in order to eliminate any residual tension from LES muscles. The stomachs were placed on a tiltable device (Fig. 1). Competency and anatomic evaluations of the fundoplications were carried out in 5 incline positions (-300, -150, 00, 150, 300). Evaluations included measurements of: the angle of His via fluoroscopy (Fig. 2), the esophago-gastric (EG) orifice area via gastroscopy and the occurrence of reflux.

Results: The angle of His was significantly different between the control and the myotomy groups, however, there was no significant difference between the Nissen and Toupet groups. The EG orifice area was significantly different between the control and the myotomy groups, however, there was no significant difference between the Nissen and Toupet groups. Reflux occurred predominantly at the incline of 150 in the myotomy group, at 0o in the control group and rarely occurred at the Nissen and toupet groups.

Conclusions: We believe that the function of fundoplication on anti-reflux mechanism is via altering the angle of His, which becomes acute and fixed. In addition, fundoplication decreases the EG orifice area thereby ultimately decreasing the incidence of reflux. This study demonstrates that creating a partial fundoplication may have the same effect on reflux as a complete wrap, thereby avoiding its’ side effects.

UPPER GI—Benign Esophageal disorders

O180—Short-term Outcome of Crural Relaxing Incision During Laparoscopic Anti-reflux Surgery; A Prospective Randomized Study

Mahmoud Abdelwahab Ali ¹ , H. Talaat¹, E. Hamdy¹, A. Elgiedie¹

¹Gastrointestinal Surgery Center, Mansoura University, Surgery, Egypt

Introduction: The degree of tension during repair of the diaphragmatic hiatus appears to be multifactorial. Surgeons utilize relaxing incisions to accomplish this tension especially the radial tension. The usage of mesh is controversial so the need for relaxing incisions represent a safe alternative.

Methods: This is a prospective randomized study of all patients who underwent right crural relaxing incision between December 2018 and December 2020. The present study aims to compare the short-term outcome of right crural relaxing incision associated with laparoscopic fundoplication versus conventional laparoscopic fundoplication only as regard the failure rates.

Results: This study included 70 patients with sliding hiatus hernia (HH) was the commonest cause in both groups (74.3 and 85.7% of cases respectively), followed by mixed HH (20% and 11.4% of cases respectively), while the remaining cases had paraesophageal HH. There was no significant difference between the two groups regarding either of the reported preoperative symptoms. The crural relaxing group proved its superiority at 1-year follow up as failure was reported in 11.4% of cases compared to 28.6% of conventional cases one.

Conclusion: the right crural relaxing incision is safe, feasible, should be standardized; allow approximation of crura associated with significantly better post-operative outcomes regarding symptom improvement, and recurrence rates compared to the conventional fundoplication

POSTER PRESENTATIONS

BARIATRICS—Endoluminal

P001—Perforated Marginal ulcer After Endosurgery for Weight Regain—History of Two Cases

Sebastian Happ ¹ , T. H. Simon¹

¹Spital Wallis/ SZO, Surgery, Switzerland

Introduction: Weight regain seems to be a frequent problem after Roux-en-Y gastric bypass (RYGB). When lifestyle interventions fail, further interventions get necessary. One of the key points in weight regain is the size of the gastrojejunal anastomosis. Re-sizing of a large anastomosis leads to a reduction of the pouch outlet. By this approach, the function of the bypass shall be restored. Beneath revision surgery, the transoral endoscopic outlet reduction is a powerful tool which has shown a high efficiency and safety in different studies.

Methods, Cases and Literature: Two patients with perforated marginal ulcers after endosurgery for weight regain had to be operated in a tertiary center in Switzerland last year. Both had secondary endoscopic reduction 8 respectively 12 years after a RYGP. The perforations happened 6 months respectively 2 years after the intervention. Other risk factors where previous ulcer in one case and short-term NSAID medication in the other. Both were female, 44 and 66 years old. They showed a generalized peritonitis and were treated in an emergency setting. After laparoscopic exploration and lavage an open repair with single stitch suturing, absorbable sutures, PDS 4.0 was performed. In one case, a suture from the Apollo System with its anchor was found in the perforation. Short-term antibiotic therapy and PPI where initialized. Pathology in both cases revealed transmural necrosis, no Helicobacter. Both recovered well, had a follow up endoscopy with a showed no further ulcer and proper healing of the mucosa. So far, we found no description of a higher incidence of ulcer or even perforations after these endoscopic procedures. After RYGB an incidence of 3-7% of marginal ulcer is reported. The major factors for the development are a triad of inflammation trough foreign body reaction, ischemia by damaged microcirculation and hyperacidity. Usually, the ulcers appear early after surgery with a mean at 12 months.

Conclusion: In our cases there where many years between the RYGP and the ulcer. In theory, suturing at the gastrojejunostomy could induce an episode of inflammation by additional foreign material. A change in microcirculation by the inflammation or tension on the tissue is also possible. Based on these physiological considerations and on the history of these cases an elevated risk for severe ulcerations after endoscopic outlet reduction interventions could be possible. The technique has a lot of benefits and shows a high safety in the literature. The potential risk of ulcera could be observed by follow up routine endoscopies. Optimizations in the field of patient selection, technical aspects like choice of the suture material, after treatment might be helpful to reduce the risk of such events.

BARIATRICS—Laparoscopic

P002—Laparoscopic Roux-en-Y Fistulo-Jejunostomy as a Salvage Procedure in Patients with Chronic Gastric Leak After Sleeve Gastrectomy

Panagiotis Lainas ¹ , E. Triantafyllou¹, V.B. Amor², N. Savvala³, J. Gugenheim³, I. Dagher¹, I.B. Amor³

¹Antoine-Béclère Hospital, Paris-Saclay University, Department of Minimally Invasive Digestive Surgery, France, ²Pasteur 2 Hospital, CHU Nice, Nice, Department of Radiology, France, ³Archet II Hospital, Nice, Department of Digestive Surgery, France

Aims: Laparoscopic sleeve gastrectomy (LSG) is the most frequent bariatric surgical procedure performed worldwide. Its most common postoperative complication is staple line leak (less than 3% in bariatric surgery specialized centers). Even though the rate of gastric leak following LSG has been remarkably reduced during the last years, the management of chronic leaks remains challenging. We present the results of a series of patients treated with laparoscopic Roux-en-Y fistulo-jejunostomy (LRYFJ) for a chronic gastric leak (> 12 weeks) post-LSG.

Methods: Data were prospectively gathered in an electronic database and retrospectively analyzed for all consecutive patients undergoing LRYFJ for chronic gastric leak in two specialized bariatric centers in France. Parameters of interest were patient characteristics, intraoperative data, post-operative complications and outcomes, length of hospital stay and follow-up. Hemodynamically unstable patients and patients presenting signs of severe sepsis were excluded from this study. Laparoscopy was attempted for all patients. Surgical technique was standardized in both centers.

Results: Between March 2017 and December 2019, 11 patients had a LRYFJ for chronic gastric leak (9 women, 2 men). Median age was 49.2 years, median weight 102 kg and median body mass index (BMI) 35.6 kg/m2. All procedures were performed successfully by laparoscopy, with a median operating time of 198 min. Mortality was null. One conversion to laparotomy was necessary (9.1%). Three patients (27.2%) presented a post-operative complication: one patient suffered pneumonia treated successfully conservatively by antibiotics, and two patients a gastro-jejunal anastomosis leak detected on postoperative days 3 and 22, respectively. Both cases were treated by antibiotics and endoscopic internal drainage. Median duration of hospitalization was 17 days.

Conclusions: LRYFJ seems to be a good surgical option for the treatment of chronic gastric leaks after LSG. However, it is a challenging procedure and should be performed in experienced bariatric centers by expert bariatric surgeons. Careful patient selection is essential since this approach should only be considered in patients with adequate nutritional status and after failure of a well conducted endoscopic management.

BARIATRICS—Laparoscopic

P003—Laparoscopic Total Gastric Vertical Plication for the Treatment of Morbid Obesity. Descriprion of the Technique and Results

Spyridon Koulas ¹ , G. Athanasiou¹, E. Stefou¹, P. Panagiotou¹, N. Zikos¹, M. Billis¹

¹General Hospital of Ioannina, Department of Surgery, Greece

Background: Laparoscopic total gastric vertical plication (LTGVP), seems to be an effective and safe alternative procedure for the treatment of morbid obesity. The aim of this study is to present our experience of LTGVP, as a restrictive operation, alternative to other bariatric procedures. It seemed to be an effective procedure due to the fact that it has the same results of weight loss compared to other surgical procedures with minimal risk of complications and of course with very low cost.

Methodology: This technique was used by one surgeon, during the last two years in the General Hospital of Ioannina, in the Northwestern of Greece. The patient was placed in supine position with a 30-degree reverse Trendelenburg position. Four trockars were placed in the typical sites, based on an ergonomic assessment (two of 11 mm and two of 5 mm). After the release of the great curvature and the dissection of short gastric vessels, interrupted sutures were used with 2-0 or 3-0 Ethibond from the angle of His to 4-7 cm of the pylorus. A vertical plication of the great curvature was performed in two layers. Two cm is the distance from the stitches and the lesser curvature and also 2 cm is the distance between each stitch. All of them getting extramucosal in order to achieve mild tension on the sutures.

Results: LTGVP was performed in 5 patients during the last 18 months (mean age 44 years old). They were 3 female and 2 male with average body mass index of 45(40-55). The mean weight loss in our patients was 45% approximately after 6 months, 60% after 12 months. Average time of follow-up was 12 months. Mean time of operation was 180(130-210) minutes and all patients were discharged from the hospital 2-3 days later. They were no postoperative complications.

Conclusion: LTGVP is an effective and safe technique, comparable to other restrictive methods: early postoperative complications of the method are minimal, without any important late complications. We must take in consideration that LTGVP is a very low cost procedure but is time consuming and a long term follow-up is advised.

Keywords: Laparoscopic total gastric vertical plication, Laparoscopic surgery

References:

• 1. Talebpour M, Amoli BS. Laparoscopic total gastric vertical plication in morbid obesity. Journal of Laparoendosc Adv SurgTech A. 2007

BARIATRICS—Laparoscopic

P004—Laparoscopic Removal of Gastric Banding and Gastric Great Curvature Plication Simultaneously in the Same Operation. Presentation of a Case

Spyridon Koulas ¹ , G. Athanasiou¹, M. Billis¹, G. Papiggioti¹, E. Stefou¹

¹General Hospital of Ioannina, Department of Surgery, Greece

The percentage of operations due to laparoscopic removable gastric banding varies greatly, ranging from 2 to 80%. Conversion to gastric bypass or laparoscopic sleeve gastrectomy, have all been investigated as re-operative procedures with varying degrees of success. Gastric banding, Roux-en-Y gastric bypass and sleeve gastrectomy are the most common bariatric surgery procedures performed worldwide. However, not all patients are willing to undergo to one of all these procedures. Laparoscopic gastric great curvature plication(LGGCP) was described several years ago and was demonstrated to be safe, with no complications and with moderate efficacy in short term.

AIM: The aim of this study is to report the efficacy and safety of laparoscopic removal of gastric banding with LGGCP.

Description of the technique: The patient, a 49-year-old man, was admitted to our hospital having endocrinologic, psychologic, caldiologic and pneumonologic report. The patient was posed in reverse Trendelenburg position of 30 degrees and four trocars, two of 11 mm and two of 5 mm, were positioned. At the beginning, the tube and the device of gastric banding was recognized and immediately removed. Then great omentum and short gastric vessels were carefully dissected. The great curvature was then folden, from the angle of His to the antrum (4-5 cm from pylorus) using 3-0 Ethibond not absorbable sutures. Tubing of the stomach was undertaken with the use of bougie tube size 44F with two layers of interrupted sutures. Analgesia and antiemetic drugs (metoclopramide) were given in order to treat nausea and vomiting. Oral fluid intake started 8-10 h postoperatively and progressed as was tolerated by the patient. The patient was discharged the hospital the second postoperative day. The patient was given an appropriate diet according to bariatric surgery and instructed to follow liquid diet for 2 weeks after which he was advanced to solid diet gradually.

Conclusion: LGGCP is a safe procedure with very few postoperative complications. LGGCP shows acceptable short term weight loss. Despite the observed durability of the gastric fold, some patients regained weight. Further studies may assess the possibility of association between weight regain observed in such patients and an increase in the size of the gastric pouch.

References:

• 1. N Khidir, M Al Dhaheri, W. El Ansari et al. Outcomes of laparoscopic gastric great curvature placation in morbidly obese patients. Journal of obesity. July 16 2017

• 2. Aayed R Alqahtani, Mohamed Elahmedi, Hussam Alamri. Laparoscopic removal of poor-outcome gastric banding with concomitant sleeve gastrectomy as a reoperative procedure. SAGES Abstract Archives

BARIATRICS—Laparoscopic

P005—Results After 3 Year of Implementation of a Bariatric Surgery Protocol in a Second Level Hospital

G. Flores Flores¹, Antonio Nieto Soler ¹ , P. Fernández Balaguer¹, A. Nieto Soler¹, A. López Farías¹

¹Merida Hospital, General Surgery, Spain

Introduction: Obesity is an international health problem as in Spain, the number of morbidly obese and overweight patients continues to increase, as do the comorbidities. In our region there was an important problem with the management of the surgical waiting list due to the large volume of patients, so we have jointly proposed the service of general surgery and Endocrinology: starting a bariatric and metabolic surgery program based on the guides of the Spanish society of obesity surgery and in the protocols of the IFSO. Resulting in the constitution of a multidisciplinary bariatric and metabolic surgery committee, who together have developed the protocol as well as the way of care for obese patients.

Material and Methods: We conducted a prospective observational study during 3 year of evolution, in our first 100 cases, with an evolutionary control of them, in percentage of weight loss, improvement of comorbidities, evolution in body mass index, and the rate of complications.

Results: Of the total of 100 patients in 44% we have performed Bypass, when they presented comorbidities such as DM2, HTA or dyslipidemia, and the remaining 66% have performed sleeve, were obese patients without comorbidities except for obstructive sleep apnea syndrome, which analyzed within our committee they would be subsidiaries of a pure and restrictive bariatric technique. 80% of our patients 6 months after surgery have achieved 70% of expected weight loss, with excellent monitoring by the endocrinology and nutrition service. 3 years are a little time to evaluate our metabolic results, there is a 100% diabetes mellitus control rate. As for arterial hypertension, we have only had a control of the disease in 45% of patients since the rest continue with medical treatment. In dyslipidemia there is a low response rate in Sleeve with a higher control rate in gastric bypasses. As acute complications in Sleeve, we had only 1, who was the eighth intervened patient, 21 years old, non-smoker, with a His-angled fistula at 96 h after surgery, with a normal contrasted gastro-duodenal esophageal series. In late sleeve complications at 9 weeks after the intervention, patient number 40 has presented abdominal pain, with imaging tests suggestive of acute diverticulitis, we made a laparoscopic approach, we identified a secondary hemoperitoneum; strangulated hernia of 12 mm trocar of jejunum, which has required intestinal resection and anastomosis. In the gastric bypass group, we have presented a case with hemoperitoneum in the candy cane cut line, secondary to an arterial branch which we have resolved by means of exploratory laparoscopy, washing and aspiration of the hematoma and a hem or lok in the problem area.

Conclusion: Bariatric and metabolic surgery is increasingly a procedure that will be required to perform in second level hospitals, because obesity is a disease that is increasing and the number of patients and health expenses, is increasing exponentially. It is necessary that during the implementation of a bariatric surgery protocol, strict inclusion criteria are implemented, to try to obtain the best possible results.

BARIATRICS—Laparoscopic

P006—Single Anastomosis Sleeve Ileal Bypass (SASI): A New Promising Bariatric Procedure

Pawel Lech ¹ , N. D. G. Dowgiallo-Gornowicz¹

¹Miejski Szpital Zespolony w Olsztyn, Bariatric Surgery, Poland

Introduction: Bariatric surgery is a worldwide recognized method of treatment of morbid obesity, and the number of procedures performed each year is still increasing all over the world. Currently, metabolic surgeons have a spectrum of over 30 different procedures, the most common of which are sleeve resection and RYGB-Roux-en-Y gastricy bypass. The search for new procedures that will enable a greater individualization of bariatric treatment is still ongoing. One of these procedures is SASI- single anastomosis sleeve ileal bypass.

Aim: The aim of the study is to present a relatively young and new bariatric procedure and demonstrate its effectiveness in a short postoperative period

Methodology: In the years 2019-2021, 20 SASI procedures were performed at the General, Minimally Invasive and Old Age Surgery Clinic in Olsztyn. 15 procedures were primary procedures, in 5 cases SASI was the revision method after sleeve gastrectomy. Patients with metabolic complications of obesity were qualified for primary SASI treatments.

Results: The mean age of the patients qualified for SASI was 36.4 years, mean BMI 41.8 and body weight 120.8 kg. The mean procedure time was 65.3 min, and the hospital stay was 2 days. 10 patients suffered from type 2 diabetes, 5 from hypertension. Rapid recovery of diabetes and hypertension was observed in all patients with metabolic complications of obesity.

Conclusions: SASI is a relatively young and new bariatric procedure, but the short-term results are very good, encouraging further research into this procedure.

BARIATRICS—Laparoscopic

P007—Revision of failed sleeve gastrectomy to one anastomosis gastric Bypass with Transhiatal sleeve migration

Nezar Almahfooz ¹

¹Almowasat Private Hospital, Surgery, Iraq

Present a case report of failed sleeve gastrectomy revised to one anastomosis gastric Bypass (OAGB), and the surgical management of coincidental sleeve migration, with short operative video.

Method: The patient is a young female who regain weight after laparoscopic sleeve gastrectomy (LSG). She was subjected to revisional OAGB, during which most of the sleeved stomach found intra-thoracic migrated with sliding hiatal hernia. The sleeved stomach dissected down with the esophagus and the crura repaired. The sleeved stomach divided with linear stapler and plicated with non-absorbable V-Loc TM suture over 36 French gastric bougie, and OAGB performed with Bypassed limb of 180 cm.

Results: Her provisional weight was 110 kg, length 156 cm, and BMI 45.2 Obesity class III. She had dysphagia and hypoglycemia after the old sleeve. Weight reached 76 kg in 3 months, with EBWL (86.6%). Patient not attending further schedule follow up. Regain weight after 3 years to 85 kg, 90 kg after 4 years and finally reached 97 kg after 7 years. Decision made to do OAGB. The operation done with no peri or postoperative complications. She attends 3 clinic visits with no postoperative complaint. She lost 25 kg EBW with a BMI of 29.6 in the last 3 months.

Conclusion: Never to omit a step of patient preoperative protocol, especially upper endoscopy. Choose the proper bariatirc procedure, remember the possibility of intrathoracic migration of sleeved stomach. Re-think of LSG regarding the mid and long term follow up.

BARIATRICS—Laparoscopic

P008—Laparoscopic Sleeve Gastrectomy in Adolescent; Pros and Cons

Mohamed Abdelgawad ¹ , M. E. El Sorogy¹, A. F. Fouad¹, M. E. Elrefei¹, H. H. Hamed¹

¹Gastrointestinal surgical center (GISC), Faculty of medicine, Mansoura University, Egypt, Department of General Surgery, Egypt

Introduction: Obese adolescent will grow in the future to obese adult with increasing burden on health care systems. Many contributing factors result in obesity such as individual, dietary, social, behavioral, and environmental factors. Multidisciplinary approaches were introduced in the previous studies for management of adolescent obesity. Non-surgical weight loss strategies like life-style modifications, physical exercise and dietary control have been crucial in obesity management; however, they have disappointing results. Pharmacological therapy has limited effect on weight control and long-term data is scarce. Consequently, growing interest emerged on the surface to obesity surgery for adolescent. Weight loss surgery remains the main stay and effective treatment for obesity and can result in loss 58% to 73% of excess body weight. Its efficacy had been proven for long-term weight control and control or even eliminating the obesity-related co-morbidities in adults. The adolescent bariatric surgery gained popularity in the last decade with increasing number of cases worldwide. Promising results from previous studies showed major improvement in co-morbidities, psychological issues, and obesity-related mortality after surgery. On the other hand, there are many concerns regarding the ethical considerations, and surgery-related complications. More-over, long-term data after surgery including quality of life, pathological eating behavior and weight regain is rare in the literature. Different surgical techniques such as sleeve gastrectomy, gastric banding, and Roux-en-Y gastric bypass had been evaluated regarding efficacy, safety and feasibility showing controversial results between different centers. High quality evidence such as randomized control studies, systematic reviews and meta-analysis regarding the safety of adolescent bariatric surgery is still deficient in the literature. And so, we conducted this study to assess the feasibility, safety, and short and long-term effects of laparoscopic sleeve gastrectomy for treatment of adolescent obesity.

Patient and Methods: This was retrospective study to evaluate the efficacy of laparoscopic sleeve gastrectomy (LSG) in obese adolescents. This study was carried out in Gastrointestinal Surgical Center, Mansoura University, Egypt. The patients’ data was collected from the prospectively maintained database in our center between 2014 to 2019.

Inclusion criteria: All adolescents aged from 12 to 20 years with body mass index (BMI) more than 40 kg/m2 or BMI higher 35 kg/m2 associated with obesity-related comorbidities were included in the study. The co-morbidities should be documented by the treating pediatrician or specialized referring physician. All eligible adolescents underwent non-surgical weight loss management such as lifestyle modifications, physical exercise, and dietary control but with unsatisfactory results within a minimum period of 12 months. Awareness of the adolescent and his or her family about the possible perioperative complications and the adherence to strict follow up program and dietary regimens.

Exclusion criteria included: Eating disorders, lack of social family support, developmental immaturity, severe and uncontrolled cardiorespiratory disease, syndromes causing obesity (Prader Willi syndrome), and endocrinal disorders affecting the weight loss such as untreated hypothyroidism and prolactinoma. Patients with history of upper GI surgery were also excluded. All patients underwent comprehensive evaluation by specialized team consisting of pediatrician, dietitian, bariatric surgeon, and psychologist before operation. Routine laboratory investigations and abdominal ultrasonography were routinely done. Upper GI endoscopy was done for patients complaining of GERD symptoms. Standard 5-port LSG was done over size 40 fr bougie starting 4 cm proximal to pylorus was done using EndoGIA stapler (Johnson and Johnson or Covidien). Follow up visits were scheduled at the outpatient clinic 2 and 4 weeks after surgery then 3, 6, 12, 18, and 24 months, then yearly. All patients were evaluated for excess weight loss, dysphagia, vomiting, eating behavior, comorbidity improvement, and any other complications.

Results: Forty patients were included in the study; 18 male (45%) and 22 female (55%) with median age was 17 years (range, 14—20). Mean preoperative body weight (BW) and BMI were 147.15 ± 36.31 kg and 52.55 ± 11.61 kg/m2 respectively. All patients had at least one co-morbidity. Osteoarthritis was the most common obesity-related co-morbidity in the study cohort (14 patients, 35%). Four patients presented with GERD symptoms, of which 2 patients underwent upper GI endoscopy before surgery to confirm diagnosis. No syndromic obesity was identified in the study cohort. Mean operative time was 119.25 min. Reinforcement of staple line was indicated in four cases. Intraoperative complications encountered during surgery were 2 patients with staple line bleeding controlled by clipping of the bleeding vessels and 2 stapling failure managed by running sutures. No blood transfusion was need intraoperatively. There was no conversion to open approach. Postoperative complications occurred in 2 (5%) patients with internal hemorrhage and were treated by laparoscopic exploration and bleeding control. Median hospital stay was 3 days without inpatient mortality. No hospital re-admission was reported in the early post-operative period. There was significant decrease in mean BW at 18 months after surgery in relation to preoperative values (147.15 vs 84.47 kg, p =  > 0.001). The maximum rate of decrease of mean BMI was at the first 6 months after surgery (52.5 vs 44.5 kg/m²) and gradually decreasing until reach 30.5 kg/m²at 24 months. The EBWL at 3, 6, 12, 18, and 24 months were 15.32, 25.96, 36.21, 39.82, and 40.84 kg respectively. All patients had achieved %EBWL < 50% at 12 months.

Seventeen patients (42.5%) had preoperative dyslipidemia (6 patients with high cholesterol and 11 with high triglyceride). The serum cholesterol and TGS reached normal values postoperatively at 18 and 24 months respectively. No nutritional deficiency was encountered in the study period during the follow up period. All obesity related co-morbidities have been resolved

Conclusion: Weight loss surgery among adolescents, however, remains far less studied and utilized. Given the inadequate results of non-surgical weight management in adolescents, weight loss surgery has become a more appealing option. Laparoscopic sleeve gastrectomy has been approved as an efficient surgical management of adolescent obesity.

BARIATRICS—Laparoscopic

P009—Safety and Efficacy Outcomes Of Three-Port Bikini Line Sleeve Gastrectomy Versus Conventional Sleeve Gastrectomy, A Prospective Cohort Study

Sherif Albalkiny ¹ , M. Qassem², G. Behairy², R. Helmy²

¹Aneurin Bevan Health Board, General Surgery, United Kingdom, ²Ain Shams University Hospital, General Surgery, Egypt

Background: Sleeve gastrectomy has gained popularity all over the world. Continuous attempts were approached toward achieving less abdominal trauma, more aesthetic outcome and reduction in postoperative pain. Bikini Line Sleeve Gastrectomy is a novel technique that offers satisfactory aesthetic outcome without derailing from the main objective of sleeve gastrectomy as a weight reduction procedure.

Objective: to evaluate the feasibility, reliability and safety of bikini line sleeve gastrectomy in getting satisfactory aesthetic outcome and efficient weight reduction.

Methods: prospective cohort study that included 85 patients underwent laparoscopic sleeve gastrectomy, between October 2018 and October 2019 at Ain Shams University Hospitals with 24 months follow up. Patients were divided into two groups, Group I (N = 40) underwent Laparoscopic Bikini line sleeve gastrectomy (BLSG) and Group II (N = 45) underwent conventional laparoscopic sleeve gastrectomy (LSG).Assessment of Patient’s scar satisfaction and percentage of excess weight loss (% of EWL). Moreover, we analysed postoperative complications whether early or late.

Findings: In terms of percentage of weight loss, no statistical difference recognized between the two groups at each point time interval from six, 12, 18 and 24 months. Moreover, regarding the scar appearance, Patients of bikini line sleeve gastrectomy significantly more satisfied than other patient underwent standard sleeve gastrectomy.

Conclusion: When performed properly in selected patients, Bikini line sleeve gastrectomy using three ports harbours high safety profile with excellent patient satisfaction outcomes despite prolonged operative time. Further large multi-centric randomized trials are warranted to obtain robust evidence.

BARIATRICS—Laparoscopic

P010—Safety of Senhance Digital Laparoscopy System in Cholecystectomy

Takahiro Sasaki ¹, T.F. Furuhata¹, M.N. Nishimura¹, T.O. Ono¹, A.N. Noda¹, T.O. Othubo²

¹Toyoko Hospital, St. Marianna University, Digestive Disease Center, Japan, ²St. Marianna University, Department of Gastroenterological and General Surgery, Japan

Background: The Senhance Digital Laparoscopy System (SDLS) is a system developed with the aim of digitizing laparoscopic surgery and performing it more safely. It can be performed with a small wound by using the same trocar as conventional laparoscopic surgery. It is possible. It will be covered by insurance for all laparoscopic surgery in 2019, and will be covered by insurance for cholelithiasis, hernia, urinary tract disease, and gynecological disease in addition to gastric cancer and colorectal cancer. We started the introduction in September 2020.

Purpose: This time, we report the treatment results and safety of SDLS in the surgery for cholelithiasis performed at our hospital.

Target, Method: Of the 42 cases of SDLS surgery performed from September 2020 to December 2021, 25 cases of cholelithiasis were examined for docking time, cockpit time, etc.

Result: The median docking time was 8.5 min (4-13 min), the median cockpit time was 24.5 min (13-81 min), and the median surgery time was 88.5 min (47-201 min) in all 25 patients. In the course of 25 cases, both the operation time and the console time tended to be shortened along with the case experience. Inflammation was strong in the 1st, 2nd, and 14th cases after cholecystitis, and SDLS was abandoned halfway and switched to normal laparoscopic surgery. No complications of Clavien Dindo IIIb were observed.

Conclusion: The introduction of SDLS in cholecystectomy was safe and could be performed without complications.

BARIATRICS—Laparoscopic

P011—The Prevalence Of, and Risk Factors For, Barrett’s Oesophagus After Sleeve Gastrectomy

Marcin MIgaczewski ¹ , A. Czerwinska¹, M. Rubinkiewicz¹, P. Zarzycki¹, M. Pisarska¹, J. Rymarowicz¹, M. Pędziwiatr¹, P. Major¹

¹University Hospital, General Surgery, Poland

Background: Sleeve gastrectomy became one of the most commonly performed bariatric procedure. There is an increasing that sleeve gastrectomy patients suffer from gastroesophageal reflux disease and its sequel such as erosive esophagitis or Barret’s oesophagus. Furthermore, several studies indicate that visceral adiposity and metabolic syndrome, which are frequently present in patients undergoing bariatric procedures, contribute to the development of BE irrespective of the presence of GERD. In our study we aim to evaluate the incidence of erosive esophagitis and Barrett’s esophagus among patients with normal preoperative esophagogastroduodenoscopy findings who underwent sleeve gastrectomy and investigate factors which may contribute to the development of EE and BE after the surgery.

Methods: We conducted a single centre longitudinal study which included patients who underwent sleeve gastrectomy and completed 5 years follow up period. Gastroscopies were performed in all patients at the end of the follow up period. Patients’ and treatment related factors were used to search for risk factors of Barrett’s oesophagus

Results: From a total of 30 patients, symptomatic reflux was reported by 17 patients (56.7%) during the follow up period. At OGD erosive oesophagitis was found in nine of those patients (30%), whereas BE was diagnosed in eight patients (27%). The median BMI at the end of the follow up period was significantly higher among patients with BE than in the groups with EE and with no endoscopic changes, 40.91 ± 6.32, 32.42 ± 5.53 and 33.25 ± 4.41 respectively (p = 0.04).

Conclusions: The prevalence of Barret oesophagus in SG patients is considerable. The risk of BE increases in patients with poor bariatric outcome. Endoscopic surveillance should be considered as part of the follow-up especially in patients with the higher overall risk of BE.

BARIATRICS—Laparoscopic

P012—Revisional Bariatric Surgery: Which the Best Choice? A Dual-Institutional Study

M.M. Lirici¹, Alessia Fassari ¹, A. Biancucci¹, M. Di Paola², B. Capasso², E. Santoro¹

¹San Giovanni Addolorata Hospital Complex, General Surgery, Italy,²San Pietro Fatebenefratelli Hospital, General Surgery, Italy

Aim: The main causes for revisional bariatric procedures are weight regain (WR), inadequate weight loss, late complications, or loss of quality of life. In this dual-institutional study we aimed to evaluate results of redo surgery for partial failure (PF) and WR after primary bariatric surgery. Primary endpoints were represented by the weight loss after revision surgery expressed as percentage of excess weight loss (EWL) and its efficacy on the treatment of metabolic syndrome and its defining components.

Secondary endpoints included peri- and post-operative complications and 30-day mortality.

Materials and Methods: A retrospective analysis was conducted on prospectively collected database in two bariatric centers in Rome: San Giovanni Addolorata Hospital Complex and Villa San Pietro Fatebenefratelli Hospital. From January 2003 to January 2020 a total of 130 patients underwent revisional laparoscopic surgery. While each patient may have had more than one indication to undergo revisional surgery, primary inadequate weight loss (< 50% EWL) at 1 year was the most common reason to qualify followed by weight recidivism (≥ 20% regaining of the weight lost). In our study, all primary procedures requiring revisions were restrictive: either laparoscopic adjustable gastric banding (AGB) 87 cases (Group 1) or laparoscopic sleeve gastrectomy (SG) 38 cases (Group 2). Revisional surgery included conversion to SG, Roux-en-Y Gastric Bypass (RYGB), one anastomosis gastric bypass (OAGB) or duodenal switch (DS). Patients were grouped according to primary procedure and type of revision.

Results: All revisional procedures proved to be effective both for PF/WR following AGB and SG. Some interesting differences were found. Bypass-type revisional procedures (functional procedures) are more effective compared to re-sleeve surgery (new restrictive procedures). Furthermore, functional procedures such as RYGB or OAGB achieve not only the highest but even the most constant weight loss over time. The impact on diabetes remission, dyslipidemia normalization, arterial hypertension, and sleep apnea is comparable.

Conclusions: Laparoscopic revisional bariatric surgery is safe and effective although experienced bariatric and laparoscopic surgeons are required. Redo surgery by functional procedures provides the best balance of long term weight loss, resolution of complications related to the primary procedure with minimal rate of perioperative complications.

BARIATRICS—Laparoscopic

P013—Concomitant Hiatal Hernia Repair with Sleeve Gastrectomy: Can Gastroesophageal Reflux be alleviated?

Arun Kumar ¹, M.S. Manav¹, S. Aggarwal¹

¹All India Institute of Medical Sciences, New Delhi, Department of Surgical Disciplines, India

Introduction: HH present in about 37-50% of morbidly obese patients undergoing bariatric surgery and 50-70% of the patients undergoing this surgery have symptoms of reflux. This study is to assess the effect of concomitant HHR in patients undergoing LSG with or without GERD using GERD Q questionnaire.

Methods: It is a retrospective analysis of prospectively maintained database involving sixty-three morbidly obese patients who underwent LSG with concomitant HHR from April 2013 to September 2019. The patients were diagnosed with HH either on preoperative endoscopy or on intraoperative assessment. They were subsequently followed for use of antacids and symptoms of GERD using GERDQ questionnaire prior to surgery and at 6 months, 12 months and 24 months after surgery.

Results: Of the 63 patients, Forty-eight patients were assessed with an average follow-up of 24 months after surgery. Around 56% of the patients had complete resolution of their preoperative reflux symptoms with significant improvement in their GERDQ scores, while 33% of the patients observed no change in their GERD Q scores. Five patients (10%) developed de novo Gastroesophageal reflux symptoms on an average follow-up of 2 years.

Conclusions: In patients of morbid obesity with HH, concomitant HHR with LSG will lead to the improvement of the GERD and decreases the chances of de novo GERD in asymptomatic patients.

BARIATRICS—Physiology

P014—Short-Term Effect of Laparoscopic Sleeve Gasterectomy on Hyperlipidemic Obese Patients

Mostafa Refaie Abdelatty Elkeleny ¹, M.A. Sorour¹, A. Askander², M.H. Gaber³, A.A. Sabry²

¹Faculty of Medicine, Alexandria University, General Surgery Department, GIT Unit, Egypt, ²Alexandria University, General Surgery Department, Egypt, ³Alexandria University, Cardiology, Egypt

Background: Obesity has become a global epidemic and major health problem in the twenty-first century; Studies have shown that weight loss reduces elevated serum total cholesterol and low-density lipoprotein (LDL) cholesterol and increases high-density lipoprotein (HDL) cholesterol. Laparoscopic sleeve gastrectomy is one of the most recent ways to treat obesity and manage weight loss in overweight patients whose options for weight loss are limited.

Objectives: The aim of this study was to evaluate the short-term effect of laparoscopic sleeve gastrectomy on lipid profile in hyperlipidemic obese patients during the nine months of post- operative care.

Methods: This prospective study was conducted on 50 hyperlipidemic obese candidates of bariatric surgery at Main University Hospital in Alexandria, Egypt from July 2020 to October 2021. Body weight, Body mass index (BMI), Waist circumference, Fasting and postprandial blood sugar, serum cholesterol, triglyceride, HDL and LDL levels were measured before and one, three, six and nine months following the surgical intervention.

Results: The mean age of the participants was 33.72-7.95 years. There was significant reduction in BMI, weight, blood sugar, Mean body mass index (BMI) of the patients before surgery was 48.59—5.78 kg/m², which was lowered to 32.58–3.91 kg/m²nine months after the intervention. Assessments showed a statistically significant increase in the serum level of HDL and a statistically significant decrease in the serum level of triglycerides, the serum level of total cholesterol and LDL. Moreover, results showed a positive correlation between lipid profile changes after LSG and preoperative variations in Age, BMI and Diabetic condition.

Conclusion: Laparoscopic sleeve gastrectomy reduces body mass and leads to improvement in glucose and lipid metabolism and lipid profile changes: decrease in Total Cholesterol, Triglyceride and LDL cholesterol and increase in HDL cholesterol in a significant way.

BARIATRICS—Physiology

P015—Laparoscopic sleeve Gastrectomy As Day-Case Ambulatory Surgery

Pedro Soares-Moreira ¹ , F. Marrana¹, D. Melo Pinto¹, T. Moreira Marques¹, T. Rama¹, R. Peixoto¹, G. Faria¹

¹Unidade Local de Saúde de Matosinhos, General Surgery, Portugal

Background: In recent years we have observed a progressive trend towards increasing complexity in ambulatory surgery. This is due to clinical and economic benefits and soundly supported by safety studies. However, day-case bariatric surgery remains controversial due to conflicting reports and absence of high-quality evidence. Laparoscopic sleeve gastrectomy has been increasingly performed as day-case surgery and proved safe in prospective studies. Nonetheless, it has yet to gain acceptance of the international bariatric surgical community. Since sleeve gastrectomy is currently the most frequently performed bariatric surgery worldwide, the authors describe their experience with a pilot study of day-case sleeve gastrectomy.

Methods: Obese patients that met simultaneous criteria for bariatric surgery (body mass index (BMI) > 40 kg/m2 or BMI > 35 kg/m2 with comorbidities) and outpatient surgery were considered eligible. Patients that were proposed to gastric sleeve were further screened for ambulatory sleeve gastrectomy. Exclusion criteria were: previous abdominal surgery, anticoagulant or anti-platelet therapy and uncompensated T2DM or sleep apnea.

Patients were enrolled between April and November, 2021. All patients were instructed to use and record vital signs using a portable device after discharge. Patients were interviewed by phone on the 1st post-operative day (POD) and seen at outpatient clinic at POD 2 and 30. A satisfaction questionnaire was conducted by telephone.

Results: Fifteen patients underwent day-case sleeve gastrectomy during this period. Mean age was 46 years old (range 21-67) and 83% were female. Median BMI was 41.5 kg/m2 (range 38.3-48.4) and 93% had obesity-related comorbidities. Mean operative time was 50 min (range 38-67). There were no intraoperative surgical/anesthetic complications. One patient stayed overnight due to intolerance to liquids in the first post-operative hours and was discharged at the following morning and one patient was admitted due to a suspected angina, with a negative workup. No post-operative complications occurred and there were no 30-day readmissions. Global satisfaction was graded 4,8/5 by all patients, all would choose day-case surgery again and recommend it to other bariatric patients.

Conclusion: This pilot study supports previous reports that day-case ambulatory sleeve gastrectomy is safe, possible and associated with excellent patient satisfaction.

BARIATRICS—Physiology

P016—Pre-operative Weight Loss is Not a Predictor of Weight Loss After Bariatric Surgery

Francisco Marrana ¹ , D. Melo Pinto¹, T. Moreira Marques¹, P. Soares Moreira¹, T. Rama¹, R. Peixoto¹, G. Faria¹

¹Unidade Local de Saúde de Matosinhos, General Surgery, Portugal

Background: Mandatory pre-operative weight loss is often required as admissibility criteria for bariatric surgery. Some authors propose that pre-operative weight loss is associated with patient compliance to dietary and lifestyle interventions, which are paramount in the management of obesity. However, there is no hard evidence confirming that pre-operative weight loss is related to the magnitude of post-operative weight loss. On the other hand, refusing bariatric surgery to patients who are unable to lose weight pre-operatively might exclude patients who need the most the surgically induced weight loss.

Aims: In this preliminary study we try to analyze if pre-operative weight change is associated with post-operative weight loss after bariatric surgery.

Methods: Retrospective analysis of 198 patients treated in a Portuguese Community Hospital between January 2018 and September 2021. Statistical analysis was performed with SPSS v. 28 and p-values < 0.05 were considered significant. Patients were analyzed regarding anthropometric data, weight change between the first outpatient visit and the day of the surgery and post-operative weight change.

Results: Most patients were female. The mean BMI was 43.1 kg/m². The most frequent surgery was gastric bypass (56.6%) followed by gastric sleeve (37.4%). Upon the first dietitian consultation, patients were proposed dietary optimization. Pre-operative weight loss was recommended but not required for surgery. In this period, 50% of the patients increased their weight and only 22.2% had a significant (> 2 kg) weight reduction. The 1 month %EWL was 26% and the 12 months %EWL was 81.5% and were not statistically different according to pre-operative weight change. Patient with pre-operative weight loss had significantly lower BMI (40.5 vs 44.5; p = 0.03) at the day of surgery, although their maximum BMI was not different. After adjustment for initial BMI and type of surgery, pre-operative weight change was not related with 1 month and 12 months weight loss (p = 0.9).

Conclusion: Mandatory pre-operative weight loss is not associated with post-operative weight loss and might exclude patients who are the most in need of surgical treatment.

COLORECTAL—Benign

P017—Review of Outcomes of Anal Fistula Plugs (AFP) in the Treatment of Complex Fistula-in-Ano

Syed Ishtiyaq Bukhari ¹, Ahmed¹, Yang², Toquero¹

¹Peterborough City Hospital, Colorectal Surgery, United Kingdom, ²Peterborough City Hospital, General Surgery, United Kingdom

Introduction: The AFP is an attractive option in the management of Trans-sphincteric fistula –in-ano. The proposed benefits of the procedure are that it is minimally invasive, safe with minimal risk to continence. We aimed to correlate between length of TranSphincteric Fistula Tract on MRI, and success rates using AFP to define its use more specifically.

Methods: Retrospective review of AFP at a District General Hospital (single surgeon’s data). Anatomically fistulae were classified on MRI as Extrasphincteric, Intersphincteric, Transphincteric, Ano-vaginal and Complex. The outcome measures were healing rates at all follow ups within 4 years, Recurrence rates within 6 weeks, Re-intervention rates and Faecal incontinence rates and cost effectiveness.

Results: The study included 33 patients (age 20-79 years), Male 22, Female 11. Majority of fistulae were transphincteric (15) and the median length of the fistula tract was 6.4 cm(2.5—18.3) cm, Median follow up was 38 months. Healing rate was 49.5% (16), with a recurrence rate of 57.5% (18). Incontinence rate was 0% and Re-intervention rate was 21% (7).

Conclusions: AFP, mostly used for Trans-sphincteric fistulae, is minimally invasive and safe procedure with very minimal risk to continence. However, the recurrence rates are high and is expensive. Study needs to be validated with prospective RCTs and other studies with longer follow up.

COLORECTAL—Benign

P018—The Incidence of Laparoscopic Approach for the Surgical Treatment of Acute Appendicitis. A Romanian Multicenter Prospective Study

Vasile Bintintan ¹, A. Bicajanu¹, S. Marginean¹, R. Vieru², D. Ciurdariu³, R. Urs⁴, R. Popescu⁵, S. Patrascu⁶, L. Stirbu⁷, L. Csaba⁸, T. Kantor⁹, A. Al Aloul¹⁰, B. Dascalescu¹¹, O. Bardac¹², I. Kiss¹³, T. Kramar¹⁴, D. Malicemco¹⁵, M. Chiiriac¹⁶, N. Iovu¹⁷, N. Fluieras¹⁸, V. Cherdivara¹⁹

¹University of Medicine Cluj Napoca, Surgery, Romania, ²Spitatlul Judetean Alba Iulia, Chirurgie, Romania, ³Spitalul Judetean Arad, Chirurgie, Romania, ⁴Spitalul Judetean Bistrita, Chirurgie, Romania, ⁵Spitalul Judetean Constanta, Chirurgie, Romania, ⁶Spitalul Judetean Craiova, Chirurgie, Romania, ⁷Spitalul Judetean Iasi, Chirurgie, Romania, ⁸Spitalul Judetean Miercurea Ciuc, Chirurgie, Romania, ⁹Spitalul Orasenesc Odorheiu Secuiesc, Chirurgie, Romania, ¹⁰Spitalul Orasenesc Ramnicu Sarat, Chirurgie, Romania, ¹¹Spitalul Judetean Satu Mare, Chirurgie, Romania, ¹²Spitalul Judetean Sibiu, Chirurgie, Romania, ¹³Spitalul Judetean Targu Mures, Chirurgie, Romania, ¹⁴Spitalul Judetean Zalau, Chirurgie, Romania, ¹⁵Spitalul Orasenesc Slobozia, Chirurgie, Romania, ¹⁶Spitalul Orasenesc Marghita, Chirurgie, Romania, ¹⁷Spitalul Orasenesc Lugoj, Chirurgie, Romania, ¹⁸Spitalul Judetean Deva, Chirurgie, Romania, ¹⁹Spitalul Judetean Caransebes, Chirurgie, Romania

Introduction: Due to lack of a nationwide registry of minimally-invasive operated patients, the real incidence of the laparoscopic approach for treatment of acute appendicitis in Romanian hospitals is not known. The aim of this study is to shed a light on this issue.

Materials and methods: A national multicenter study prospective study was conducted during a 6-month period, form 15 May to 15 November and included hospitals of all categories: 6 university hospitals, 9 county hospitals, 6 municipal hospitals and 1 private hospital. Inclusion criteria for the hospitals was the willingness to record data in a prospective manner. All patients with acute appendicitis operated both open and laparoscopic were enrolled in the study.

Results: 588 patients were included din total, of which 562 adults, 6 pregnant women and 20 minors aged between 9 and 17 years. Of these 274 (46.6%) were operated laparoscopically while 313 patients (53.2%) were operated with an open of which 294 with McBurney incision (50%), 19 (3.2%) with Jalaguer incision and 1 (0.2%) oblique inguinal incision. The incidence of laparoscopic appendectomy was 100% in the private hospital, 72,3% in university hospitals, 37.3% in county hospitals and 29.5% in city hospitals. The overall conversion rate was 6.93%. The wound infection rate was significantly higher in the open vs the laparoscopic group (7.9% vs 2.4%). The average postoperative hospital stay was also significantly lower in the laparoscopic group (4 vs 6 days, respectively).

Conclusion: In this sample of 22 hospitals that cover the entire diversity of Romanian hospitals, the incidence of laparoscopic appendectomy aims towards 50% and is higher than expected. Probably there is a selection bias, probably younger, enthusiastic surgeons were more eager to take part in a prospective trial. However, it shows a trend in Romanian surgery toward modernization that is clearly led by the new, young generation of surgeons now used with minimally-invasive surgery from their training as residents.

COLORECTAL—Benign

P019—A New Endoscopic Approach to Investigate the Length of Involvement of Acutely Ischaemic Bowel Without Surgery

Ahmed Baban ¹, K. Shalli²

¹Hawler Medical University, Surgery, Iraq, ²University Hospital Wishaw, Surgery, United Kingdom

Aims: The acurate assesment of remaining bowel viability following an acute bowel ischaemia can not be obtained by CT scans alone. Ultimate diagnosis involves invasive surgical techniques under general anaesthesia particularly in younger age group. We present a case were an endoscopic assessment using a paediatric colonoscope was performed in an acutely unwell patients. The aim was to avoid a potential futile explarotory surgery.

Methods: A 52 years old patient with no major ill health presented acutely unwell as an emergency. Case note review and CT imaging was analysed. A new approach was undertaken by using a paediatric colonoscope to assess accurcey of bowel length that is still viable in small bowel ischaemia to indicate or avoid definitive surgical intervention.

Results: Findings from CT scan was of diffuse bowel ischaemia in a young patient and no prevoius major comoribidity. Paediatric colonoscope that have similar width and nearly double the lengtho of a standard gastroscope was used and confirmed ischaemic changes starting at 20 cm (Fig. 1) and severe ischaemia at 30 cm (Fig. 2) from duodeno-jejunal junction. Therefore exploratory surgical intervention was avoided and palliative support was started.

Conclusion: Successful visualisation of small bowel lumen using the paediatric colonoscopic can accurately assess the viability of bowel without a a diagnostic surgery under general anaesthesia. This permits a less distressful procedure to determin definitive management in younger patients who are fit but an unnecessary surgery can be avoided were the outcome would remain remain poor. It makes management options of intervention or palliation easier.

COLORECTAL—Benign

P020—Ustekinumab and Surgical Resection in Synchronous Rheumatoid Arthritis, Sjögren's syndrome and Pan-Colitis of Crohn’s Disease

Chou-Chen Chen ¹ , C.P. Chen¹, Y. K. Tseng¹

¹Taichung Veterans General Hospital, Department of Surgery, Taiwan

Aims: Biological agent has been used in various autoimmune diseases more than 15 years. Patients with rheumatoid arthritis (RA), Sjögren's syndrome (SS), ulcerative colitis (UC) and Crohn’s disease (CD) could be beneficial for joint pain relief, gastrointestinal upset resolution, renal function preservation, and life quality improvement. New biological agents are rapidly being introduced years by years.

Method: We presented treatment course on a patient with synchronous multiple autoimmune disease of RA, SS, and colonic CD. The previous biological agent and oral corticosteroids did not suppress inflammatory status of lower gastrointestinal tract. The patient suffered a critical episode of colonic Crohn’s disease perforations at ascending and sigmoid colon. We resected the diseased segment of colon with temporary end ileostomy, then applied ustekinumab for maintenance her bowel function, and record a series of neurophil-lymphocyte ratio (NLR) as evaluation tool of biological effectiveness on multiple autoimmune disease.

Results: This 58 years-old female patient had RA diagnosed at age 28, and subsequent SS and CD noted for more than 16 years with regular corticosteroids imuran and selective, B-cell depleting biologic agent treatment ( rituximab since 2017), failure 14 months later, then shifting to tocilizumab until now. She had acute on chronic abdominal pain, then visited emergent room, elevated WBC up to 11560 m/L and CT of abdomen showed multiple site colon wall thickening and moderate ascites. After emergent resection for skip lesion of pan-colitis Crohn’s disease and application of ustekinumab, the patient had well appetite, body weight gain, and life quality. The NLR had positive response after operation and ustekinumab with 2-months observation. We would like to reconstruct the bowel in the future.

Conclusion: Same as SNQ awarded experience, we emphasized the cooperation between gastrointestinal surgeons, ostomy and wound nursing care, parenteral or enteral nutritional supplement, social workers that made patient recovery soon in mood and physical field. The ustekinumab provided rapid and sustainable improvement in bowel function and symptomatic relief for patient with synchronous multiple immune disease, RA, SS and CD in every 8 weeks medication. The safety profile of ustekinumab is consistent with that of other immuno-modulator agent. The long term efficacy of ustekinumab is still going on evaluation in patients with multiple autoimmune disease.

COLORECTAL—Benign

P021—A Novel Approach to Bezoar Extraction

Balaji Jayasankar ¹ , K. Abdelsaid¹, Y. Abdul Aal¹, C. Bailey¹

¹Maidstone and Tunbridge Wells NHS England, General Surgery, United Kingdom

Aims: Case describing a novel extraction of bezoar by using a combination of endoscopy and open procedure.

Methods: A young girl presented with a confounding clinical picture of abdominal pain, not tolerating oral feeds on a background of being hypoalbuminemic and anemic. She had been evaluated at multiple instances in the past for similar complaints. On further evaluation this turned out to be secondary to a bezoar lodged in her stomach and small bowel. This had been causing her severe distress over a period of 6 months with significant weight loss.

Methods: Extraction of the bezoar by gastroscopy was not possible and she was taken up for surgery. Intra-operatively, we describe a novel method of extraction of the bezoar by using laparoscopic instruments through the incision over the gastric wall and extraction of the bezoar.

Results: A novel approach to an extraction of bezoar by a synergistic method using laparoscopic instruments aided by open procedure.

Conclusion: An interesting clinical approach to bezoar extraction

COLORECTAL—Benign

P022—Stump Appendicitis Secondary to a Faecolith, a Diagnostic Dilemma

Maheen Rana ¹ , A. Mehmood¹, H. Almadani¹, M. Caldwell¹, M. Aremu¹

¹Sligo University Hospital, General Surgery, Ireland

Aim: We present an unusual case of a 41 year old lady with stump appendicitis secondary to an impacted fecalith after 30 years of open appendicectomy.

Method: A 41 year old lady was admitted to our surgical unit with four days history of abdominal pain at the right iliac fossa, and on examination, she was tender at the site. She had an open appendicectomy as a child. Blood investigations showed normal inflammatory markers and Abdominal CT showed a 7 mm faecolith in appendix stump without acute inflammatory changes. She underwent a diagnostic laparoscopy due to persistent symptoms. She had a 10 mm stump with adhesions between right colon and lateral abdominal wall without any gross evidence of inflammation, intra-abdominal collection or obstruction. The appendiceal stump was resected and histopathology confirmed mild acute inflammatory changes.

Results: Patient’s symptoms resolved following the resection of the appendiceal stump and she was discharged the following day. She was reviewed in the outpatient clinic six weeks postoperatively, and she remained asymptomatic.

Discussion: Stump appendicitis is the inflammation of the remnant portion of the appendix. It is an under recognized condition with reported incidence of 1 in 50,000 appendicectomies. The time interval between appendicectomy and stump appendicitis is variable and can range between 1 day to 60 years. Appendiceal stump longer than 25 mm is most important factor associated with stump appendicitis as can become the reservoir for faecolith and cause inflammation, though the stump length in this case was 10 mm. Stump appendicitis presents with right sided abdomen pain typical of acute appendicitis, however, with history of appendicectomy, diagnosis of stump appendicitis could be difficult and often delayed. This may even go unrecognized in the absence of florid changes on imaging or diagnostic laparoscopy. This prompts the need to consider the diagnosis of stump appendicitis in every individual who present with right sided abdominal pain and has a past history of appendicectomy.

COLORECTAL—Benign

P023—Endoscopic Resection of Colonic Lipoma: Case Series

Guh Jung Seo ¹ , K. J. Cho¹, H. S. Cho¹

¹Dae Han Surgical Clinic, Department of Colorectal Surgery, Korea

Aims: In colonic lipoma, colonoscopic biopsy is not recommended in patients suspected of colonic lipoma because the lesion is beneath the normal mucosa. The exat diagnosis still mainly relies on pathologic examaination. In addition, biopsy may increase the risks of bleeding and perforation.The aim of this paper was to report and discuss the safety of endoscopic resection for accurate diagnosis in patients with colonic lipomas.

Methods: The patients enrolled in this study were five patients with colonic lipoma who underwent endoscopic partial resection. All medical records, including characteristics of the patients, lipomas, complications, were retrospectively reviewed.

Results: The five patients were all women, with a mean age of 65.8 years (range, 54-78 years). Location of the colonic lipoma was 2 in cecum, 2 in ascending colon, and 1 in sigmoid colon. The tumor shape was all submucosal tumors. All detected tumors were removed by endoscopic partial resection after submucosal injection of epinephrine-saline mixture 1:100 000. The endoscopic mean size of tumors was 13.4 mm (range, 10-20 mm). The pathologically measured mean size of the resected specimens was 8.6 mm (range, 5-10 mm). Bleeding prophylaxis was performed in 2 cases by applying a hemoclip Of the five patients, 2 patients were admitted. Endoscopic resection in all cases was performed without any complications. Histopathological examination of the all resected tumor revealed mature adipose tissue in submucosal layer, and there was no evidence of malignancy. It was diagnosed as a submocosal lipoma.

Conclusion: Endoscopic resection is considered to be a relatively safe and useful method for diagnosis and treatment of colonic lipoma.

COLORECTAL—Benign

P024—Scoring System for Predictive Factors of Complicated Appendicitis

Mostafa Refaie Abdelatty Elkeleny ¹ , O. Gamaleldin², M. Magdy³, A. Al Argawy³, M. Saif Eldin³

¹Faculty of Medicine,Alexandria University, General Surgery Department, GIT Unit, Egypt, ²Faculty of Medicine,Alexandria University, Radiology Department, Egypt, ³Alexandria University, General surgery department, Egypt

Background: Acute appendicitis is the most common surgical emergency and for decades the surgical intervention was considered the standard treatment; but recently the conservative approach appeared as effective as surgical intervention in the treatment of non-complicated appendicitis. however, the application of this conservative approach needs the differentiation between complicated and non-complicated appendicitis which still challenging as no single parameter either clinical, laboratory or radiological can do this differentiation alone; but augmentation of these parameters together in a score can do.so in this study we formulate a scoring system from these parameters that can be used to predict complicated appendicitis.

Aim of the work: formulate a scoring system for prediction of complicated appendicitis.

Patients and Methods: 50 patients diagnosed as acute appendicitis clinically and by ultrasound and each patient get a score before being submitted to surgery then matching the intraoperative finding for each patient with the preoperative score to test the validity of this score for prediction of complicated appendicitis.

Results: the number of patients in the complicated group versus the non-complicated group was 18(36%) and 32(64%) respectively; with the mean score for the complicated group (gangrenous or perforated) 6 while for the non-complicated group (catarrhal or suppurative) 3.5.

Conclusion: this scoring system considered valid for prediction of complicated appendicitis with cut off point > 4

COLORECTAL—Benign

P025—Videolaparoscopy in the Treatment of Colon Diverticular Bleeding

V. Shapovalov¹, Diana Karadyaur ¹ , O. Tymchuck², M. Kashtalyan³, D. Karadyaur¹

¹Military-medical Clincial Center of the Southern region, Odessa, Ukraine, Coloproctology, Ukraine, ²Military Medical Clinical Center of the Eastern Region, Dnipro, Abdominal surgery, Ukraine, ³Odessa National Medical University, Odessa National Medical University, Ukraine

Objective: to analyze the experience of treatment of patients with diverticular disease of the colon, complicated by bleeding.

Materials and Methods: The treatment of 221 patients was analyzed, hospitalized in the Military Medical Clinical Center of the Southern region of Odessa who underwent 263 surgeries for the diverticular disease of the colon and its complications. Intestinal bleeding as a cause of hospitalization was noted in 17 (7.6%) patients.

Results and Discussion: Bleeding was stopped by conservative methods in 9 patients. 8 patients underwent surgical treatment. The following surgical interventions were performed: laparoscopic left hemicolectomy (4), laparoscopic resection of the sigmoid colon (1), left hemicolectomy (3), and right hemicolectomy (1). In laparoscopic left hemicolectomy the average duration of operation made 205 ± 12.5 min. The average duration of the postoperative period was 9.75 ± 1.2 days. In left-sided traditional hemicolectomy, the average duration of the operation was 215 ± 16.3 min, the average duration of the postoperative period—14.5 ± 2.1 days.

Conclusions: our experience showed the relative duration of surgery both in laparoscopic and "traditional" open one, the duration of the postoperative period in laparoscopic intervention was lower, the intensity of pain and the recovery time of the bowel function in the group of patients who was performed laparoscopic surgery was also lower compared to traditional access operations.

COLORECTAL—Benign

P026—Acute Appendicitis, Should It Always Be Performed Laparoscopically?

Julio Gavilán Parras ¹ , R. Escalera-Pérez¹, S. MacMathuna¹, D. Raposo Puglia¹, S. Martín-Arroyo¹

¹Jerez de la Frontera University Hospital, General Surgery, Spain

Aim: Acute appendicitis is one of the most frequent surgical emergencies, the laparoscopic technique is the most widely accepted approach. However, after the publication of some articles defining a higher rate of intra-abdominal complications after laparoscopy, there is still some controversy on which technique should become the gold standard. The objective of this study is to compare the results obtained by our service and compare the techniques.

Methods: We have designed a cohort study, patients intervened with appendectomy in 2021 in the Hospital of Jerez De La Frontera were included. We analysed the cohorts depending on the technique using SPSS version 22., the variables we studied were: Length of stay, appearance of complications (within 30 days), need for postoperative antibiotics and Clavien-Dindo Score.

Results: We performed a total of 190 appendectomies in 2021, 41 of which were performed through open surgery and 149 laparoscopically. The open surgery group (OS) had a mean stay of 3.5 (SD 3.4) days while the Laparoscopic group (LA) had a mean stay of 3 (SD 2.9) days (P = 0.3). 6 patients (14%) who underwent OS suffered from postoperative complications while the LA group registered 16 (10.7%) patients who suffered them (P = 0.5) (Chart 1). Antibiotics were needed in 17 (41.5%) patients after the intervention in the OS cohort and in 48 (32.2%) in the LA group (P = 0.25). Scores in the Clavien-Dindo Classification were below II in 36 (87.7%) patients in the OS group and in 141 (94.6%) in the LA group. The OS cohort had 5 (12.3%) patients scoring III with no one scoring over IV, whereas 6 (4%) patients scored III in the LA group. Two patients scored over III in the LA group; one needed intensive care after a postoperative cecal fistula, one death was registered due to an aggressive leukaemia(P = 0.3) (Chart 2).

Conclusion: Although no statistical differences were found, clinical results are more favourable in those patients who underwent the laparoscopic intervention, as this intervention has proved to reduce hospital stay and postoperative pain, we recommend to choose the laparoscopic approach for appendix surgery.

COLORECTAL—Benign

P027—Indication for Laparoscopic Approach in Surgical Treatment of Pelvic Floor Disorders in the Posterior Compartment, Is There a Conclusion?

Valentin Sojar, J.T. Jakomin²

¹Iatros Medical Centre, Medical Centre, Slovenia, ²Izola General Hospital, Surgery, Slovenia

Introduction: Pelvic floor disorders (PFD) are a broad spectrum of symptoms in three pelvic compartments. Clinical presentations such as internal and open rectal prolapse, rectocele, enterocele, fecal incontinence and constipation are predominately signs of defects in posterior department. PFD affects nearly 60% of women in postmenopausal age, young and nulliparous could be affected and male patients as well. Due to complex presentation patients present themself to different medical specialists primarily. In a proctology setting patients with rectal prolapse, obstructed defecation and constipation are seen. Diagnosis should be confirmed with careful patient's history, detailed clinical examination and more than one diagnostic procedure (pelvic floor US, defecography, manometry, colonoscopy) to define morphological and functional deficits. Obtaining Continence and Obstructed defecation scores and Quality of life questionnaires are mandatory. Patients should always be approached first with conservative measures like dietary consultation, pelvic floor rehabilitation and other life style changes. Leading symptoms and grade of presentation are the usual reasons for potential surgical treatment for very selected patients.

Various surgical approaches to correct PFD are known: perineal, open, endorectal, laparoscopic, robotic, with resection of bowel or not. In the last decades, MIS gained popularity because of minimal harm and good results. On the other side laparoscopic technique is demanding, more expensive and has a longer learning curve. Robotic surgery may have some advantages, but is even more expensive and limited.

Before surgical intervention one should answer two questions taking into account grade of symptoms, clinical findings and clear proof of functional or anatomical deficit:

• 1. Is there a clear indication for surgery?

• 2. What kind of procedure to perform?

Concomitant symptoms, age, previous surgery, other diseases and patients’ preference are mandatory to discuss. Surgeons’ expertise is very important.

Methods: In our practice we have developed a standard process to define appropriate patient specific treatment and procedure. As a proctology unit, approximately 900 pts/y with some degree of PFD in the posterior department visit our clinic as a first visit. During this visit leading symptoms are usually defined. Digital rectal examination, proctoscopy and rectoscopy roughly determine potential anatomical defects. Next steps are proposed in long lasting and very symptomatic patients: conservative treatment and further diagnostics. In the case patients have developed symptoms and do not have clear contraindications, potential surgical approach is discussed already at the first visit. Next pelvic floor US, defecography, manometry, EMG of pelvic floor (very exceptional) is indicated. Patients are referred to dietary consultation and physiotherapist. Patients with signs of constipation are sent to radiopaque markers transit time and CT colonography. Female patients with signs of middle and anterior compartment PFD are referred to urogynecologist. Usual time to finish work-up and conservative treatments is about 6—8 months. Internal MDT team (Iatros MC) discuss about 250 pts a year during and after work-up and treatments. At the end surgical treatment is discussed with 40—50 pts/y. Indications for surgery are: degree of symptoms, clinical findings and unsuccessful conservative treatment. Surgical correction is finally and only offered to those patients who ask for it!

Proposed surgical treatments are:

• Laparoscopic rectopexy (without resection) for internal and open rectal prolapse, rectocele and enterocele,

• Perineal resection for open rectal prolapse,

• Delorme procedure for internal prolapse,

• Perineal correction of rectocele and enterocele.

• Subtotal colectomy for CIC (laparoscopic)

Conclusion: Unfortunately it is not possible to give a clear conclusion. Due to complexity of symptoms and clinical findings it is very difficult to define a standard surgical procedure for PFD correction. Low complication rate, fast recovery and surgeons’ preference are the main reasons for laparoscopic approach in our clinical practice.

COLORECTAL—Benign

P028—Is "Zaragoza" Technique for Laparoscopic Appendicectomy, Useful At Any Stage?: Series of Cases

A. Luis Vargas Ávila¹, Yunuen Ailyn Morales Tercero ¹ , S. J. Salgado Arzate¹, J. Vargas Flores¹, Y. S. Castillejos Márquez¹, A. Jimenez Leyva¹, J. A. Dominguez Rodriguez¹, I. De Alba Cruz¹, H. F. Narváez González¹, J. Chernitzky Camaño¹, A. J. Lara Valdez¹, Y. A. Morales Tercero¹, L. Perna Lozada¹, A. U. Ávila Rosales¹, C. L. Flores De la Canal¹, L. G. Luna León¹

¹ISSSTE Zaragoza, Surgery, Mexico

Aims: Appendectomy continues to be one of the most frequent emergency surgical procedures, currently with a high preference for laparoscopic management worldwide. Laparoscopic technique execution is currently reported in the range of 46 to 58%, even up to 90% in some countries, with an open conversion rate of 8.6%.

Objective: Present a series of cases resolved by laparoscopic appendicectomy using the "Zaragoza" technique and its results.

Methods: Cohort study of patients diagnosed with more than 150 were operated with the Zaragoza technique. We placed a 10 mm trocar in the umbilical scar, two other 5 mm trocars in suprapubic midline and or silk sutures are placed, knotted and the appendix is cut between the two sutures, finally mesoappendix is cut with harmonic scalpel or bipolar clamp.

Results: Appendicitis in all phases were included, within our results we had 0% conversion to open surgery, 0% mortality a quick recovery and early discharge.

Conclusion: Various methods of laparoscopic management for appendectomy are reported in the literature, from trocar placement, appendicular stump management and surgical specimen extraction, with a wide range of results. We have obtained good results in patients undergoing the technique we are reporting. The Zaragoza technique, which was used for laparoscopic appendectomy, is an effective and safe option that prevents excessive manipulation of the inflamed appendix and is also easily reproducible.

COLORECTAL—Benign

P029—Complicated Retroileal Appendicitis with Retroperitoneal Abscess Resolved by Laparoscopy

I. de-Alba Cruz¹, Avila Rosales Angel Uriel ¹ , V. A. Arcenio Luis¹, S. A. Silvia Jacqueline¹, V. F. Julian¹, C. M. Yazmin Chantal¹, J. L. Amador¹, D. R. Jorge Alejandro¹, M. P. Jesus Antonio¹, N. G. Hugo Fernando¹, C. C. Jonathan¹, L. V. Angel Javier¹, M. T. Yunuen¹, P. L. Luisana¹, F. C. Cintia Lorena¹

¹Hospital Regional Gral Ignacio Zaragoza, Surgery, Mexico

Aim: Report the case since the presentation of retroileal appendicitis is rare as well as laparoscopic surgical management in these cases.

Methods: 36-year-old female with no significant history. She started 48 h prior to admission with colicky diffuse abdominal pain of intensity 7/10, radiation to the lower quadrants, nausea, emesus and fever. EF: tender abdomen in lower quadrants, positive rovsing, positive mcburney, negative von blumberg. Laboratories: leucos 14.3, neutral 70. Surgical time is requested to perform laparoscopic appendectomy.

Results: A laparoscopic approach was performed with 3 ports (10 mm umbilical, 5 mm supraubic, and 5 mm left flank) with pneumoperitoneum at 14 mmHg. Reaction-free liquid is found in 80 cc abdominal cavity, plastron made up of cecum, terminal ileum and cecal appendix which is retroilel adhered to terminal ileum mesentery. The plastron is dissected until finding a retroileal cecal appendix with necrotic patches as well as a perforation in the integral middle third base, which is firmly adhered to the mesentery. A 10 cc retoperitoneal abscess is found, which is drained, a mesoappendix dissection is performed at the appendicular base level, a seromuscular point is made at the appendicular base level with 2-0 silk, an intracorporeal knot is made, securing the appendicular stump. A cecal appendix cut is performed with harmonic and a meso-appendix cut is continued. The piece is extracted and sent to pathology, the surgical site is washed, penrose drainage is placed, ports are removed and the procedure is considered completed. Patient with adequate evolution is discharged on the third day.

Conclusions: The laparoscopic approach remains the gold standard even for complicated appendicitis. The seromuscular point at the appendicular base is an efficient resource for stump management in complicated appendicitis

COLORECTAL—Benign

P030—Management of Adult Intussusception in the Recent Era of Advanced Laparoscopy and CT: A Case Report and Literature Review

Mohamed Salama ¹, A. Salama², S. Babur¹, A.R. Nasr¹

¹Our Lady of Lourdes Hospital, General Surgery, Ireland, ²NUI Galway, School of Medicine, Ireland

Introduction: Intussusception is a rare condition in adults that represent only 1% of all intestinal obstruction and 5% of all intussusception cases. Its presentation and clinical signs are often variable and nonspecific so the diagnosis is difficult. The optimal management strategy for adult intussusception remains controversial as to whether it should be conservative vs operative (open vs lap). Surgical management continues to be the main stay treatment. There is no consensus on whether laparoscopy can be applied to adult intussusception with respect of safety and efficacy.

Case report: A 26 Year old lady presented with abdominal pain, altered bowels and weight loss for six months. She has a past medical history of sarcoidosis, cardiac disease, Type 1 Diabetes and had a normal OGD and colonoscopy. CT was highly suggestive of small bowel intussusception. A diagnosis of jejuno-jejunal intussusception was confirmed by laparoscopy. Neither ischaemic nor substantial inflammation was evident. Laparoscopic exploration of the entire bowel was done. A reduction of the intussusception was performed laparoscopically. The affected segment was exteriorised via the side of umbilical port and examined manually and there was no underlying pathology. The patient had an uneventful recovery and discharged the next day post-operatively.

Conclusion

• Laparoscopic surgery for adult intussusception is currently feasible and safe with a few technical points that need consideration: the distended intussusception should be grasped as widely as possible to disperse the tearing force; two non traumatic bowel clamps should be used for bowel manipulation; if resistance is felt at any time during the traction, bowel reduction should not be continued and en block resection laparoscopically seems safe; if the intra-operative manipulation of the intussusception appears dangerous due to massively dilated bowel or reduced space, conversion to open surgery is indicated.

• The choice of laparoscopic or open surgery for intussusception depends on clinical condition of the patient, the location and extent of intussusception, the possibility of underlying disease and the availability of experienced surgeon.

COLORECTAL—Benign

P031—Non-steroidal Anti-inflammatory Drug (NSAID) Induced Diaphragm Disease: A Rare Cause of Small Bowel Obstruction—Case Report and Literature Review

Mohamed Salama ¹ , A. Salama², F. Kazi³, B. Sami¹, A.R. Nasr¹

¹Our Lady of Lourdes Hospital, General Surgery, Ireland, ²NUI Galway, School of Medicine, General Surgery, Ireland, ³Trinity College Dublin, School of Medicine, Ireland

Introduction: NSAIDs are the most commonly prescribed drugs worldwide and they are known to be associated with upper GI complications. However, NSAID-induced small bowel stricture known as diaphragm disease was first described by Long Et Al in 1988. Its diagnosis is challenging. We present a rare case of a 50 year old male who after an extensive diagnostic workup and small bowel resection for obstructive symptoms, was finally diagnosed with NSAID-induced diaphragm disease as confirmed by histology.

Case report: A 50 year old male presented with intermittent epigastric pain, vomiting and abdominal distension for 2 years. He has a background history of type 2 Diabetes Mellitus, hyperlipidaemia, total hip replacement, post-traumatic chronic shoulder & cervical spine pain, and chronic anaemia. His medications include anti-diabetics and NSAIDs. He had a normal OGD and colonoscopy previously and capsule endoscopy 2 weeks before reported enteritis with concentric ulceration and strictures. CT on this admission reported multiple dilated loops of small bowel with transitional point in the terminal ileum—query internal hernia and adhesions. He underwent laparoscopy which showed small bowel dilatation with a transition point in the ileum caused by multiple strictures in one segment. This segment was resected with primary anastomosis. No other small bowel pathology was identified intra-operatively. Histology reported ulceration and fibrosis in keeping with diaphragm disease with no evidence of Crohn’s or vasculitis. He made a good recovery and was advised to discontinue NSAIDs. He was still well at clinic a few months later.

Conclusions: As surgeons frequently deal with small bowel obstruction, it is important to consider NSAID-induced enteropathy. The diagnosis is challenging as symptoms are often nonspecific and radiological studies remain inconclusive. Surgical resection is curative provided NSAIDs are discontinued. Drugs that could prevent or treat NSAID-induced enteropathy have not been developed. Follow up of these cases is needed as recurrence rate is up to 50% due to failure to appreciate the extent of lesions at the initial operation or due to continued use of NSAIDs.

COLORECTAL—IBD

P032—Fistulating Crhon's Disease, Non operative Treatment of Fistula Closure Using Coils and Glue

Iyad M H Maqboul ¹

¹Najah National University Hospital, General Laparoscopic Surgery, Palestina

A 34 years old female patient is a known case of inflammatory bowel disease Crohn’s disease since 10 years with initial presentation of watery diarrhea, abdominal pain & distention, with decrease in body weight, managed conservatively and kept on pentasa. Her medical condition was complicated by multiple attacks of crohn's disease exacerbation, colonic perforation, subcutaneous abscess, and enterocutatnous fistula. As part of her management, the patient underwent ileocecectomy done with end to end ileocolic anastomosis which was later on complicated by an abscess collection at the site of laparotmy scar, and enterocutatnous fistula, with the cutatnous opening being the middle of the laparotomy scar. Embolization with Glu injection and coiling was done for the fistula which showed an excellent result.

COLORECTAL—Malignant

P033—The Role of Transanal Compared to Laparoscopic Total Mesorectal Excision for the Treatment of Rectal Cancer in Obese Patients: A Multicenter Propensity-Matched Analysis

Patricia Tejedor ¹, J. Arredondo², L.M. Jiménez¹, V. Simó³, J. Zorrilla¹, J. Baixauli², C. Pastor²

¹University Hospital Gregorio Marañón, Colorectal surgery, Spain, ²University Clinic of Navarre, Colorectal Surgery, Spain, ³University Hospital Rio Hortega, Colorectal Surgery, Spain

Aim: To compare the rate of sphincter-saving interventions between transanal Total Mesorectal Excision (taTME) and laparoscopic Total Mesorectal Excision (lapTME) in a challenging group of obese patients with rectal cancer.

Methods: A multicentre retrospective review was performed selecting consecutive patients diagnosed with rectal cancer below the peritoneal reflection and BMI ≥ 30 kg/m2, who underwent minimally invasive elective surgery. Exclusion criteria were 1)sphincter and/or puborectalis invasion; 2)multivisceral resections; 3)palliative surgeries. The study population was divided into two groups according to the type of intervention: taTME or lapTME. A propensity-matched analysis was performed in a 1:1 design based on gender and neoadjuvant chemoradiotherapy (nCRT).

Results: A cohort of 93 patients over a 5-year period were included. Of them, 41 underwent taTME (44%) and 52 lapTME (56%); median age 67 (56-75) yrs, male:female 66:34, median BMI 32 (31-33) Kg/m2. Median tumour height was 6 (5-8) cm, 61% received nCRT, with an overall percentage of sphincter-saving surgery of 83%. A total of 41 patients who underwent taTME were case-matched with 41 patients who underwent lapTME. In the taTME group, 51% had low rectal cancer compared to 32% in the lapTME group (p = 0.141); however, the rate of sphincter-saving surgery was significantly higher in the taTME group (95% vs. 71%, p = 0.003). There were no conversions in the taTME group, compared to 3 cases in the lapTME group (7%) (p = 0.078). The percentage of major complications was similar (10% taTME vs. 7% lapTME, p = 0.275), including the rate of clinical anastomotic leak (8% taTME vs. 15% lapTME, p = 0.377). Pathological outcomes were similar; median distal resection margin was 10 mm in both groups, there were no cases of affected distal margin in the taTME group vs. 3 cases (7%) lapTME, p = 0.079). The quality of the mesorectum and the circumferential resection margin were similar in both groups.

Conclusions: In our experience, the transanal approach has improved the rate of sphincter-saving surgery in a very challenging group of obese patients, diagnosed with mid-low rectal cancer.

COLORECTAL—Malignant

P034—How to Improve Participation and Compliance During Prehabilitation?—PACE Study

Misha Sier ¹ , M. Cox¹, T. T. T. Tweed¹, N. Servaas¹, J. H. M. B. Stoot¹

¹Zuyderland Medical Center, Surgery, The Netherlands

Introduction: Prehabilitation has been postulated as an effective preventive intervention to improve surgical outcomes, particularly for elderly patients with a relatively high risk of postoperative complications. Several studies have reported difficulties in recruiting patients to participate in prehabilitation programs and establishing optimal compliance. The aim of this study was to explore how participation and compliance can be improved in prehabilitation programs by systematic literature review and in-depth interviews with participants.

Methods: This study consisted of a systematic review of the literature combined with qualitative research in the form of interviews with patients who have participated in a prehabilitation program. The PubMed, Cochrane Library and EMBASE databases were searched to identify articles reporting motivators or barriers for participation in and compliance to preoperative prehabilitation programs. Programs had to entail an exercise and/or nutritional intervention and a duration of ≥ 7 days. All patients participating in the prehabilitation program were eligible for participation. The primary endpoints were factors facilitating or affecting participation and compliance to prehabilitation programs.

Results: Forty-five studies/articles, of different designs, involving 2734 patients were included. In total, 716 participants were included in the qualitative researches and 2018 patients participated in interventional studies. Six patients were interviewed, non-participating patients were asked for the main reason to decline. Participation and compliance were examined on five main themes; information provision; reasons for participation; physical exercise; nutrition; psychological intervention. The results of this study emphasize the importance of adequate patient education, in-hospital exercising with supervision and a patient-centered program. Most often, logistical problems, physical condition and impact of cancer diagnosis were reported as barriers for prehabilitation. To date, there remains a paucity of evidence for the optimal method to increase compliance to the nutritional and psychological interventions.

Conclusion: Participation and compliance is affected by numerous factors. In order to increase participation and compliance, adequate information provision, a patient-centered program, and eliminating logistical barriers are important. Future studies will have to be conducted to assess the vision of patients that declined participation. In addition, the effectiveness of interventions to improve participation and compliance should be evaluated.

COLORECTAL—Malignant

P035—The Optimal Pain Management for an Enhanced Recovery Program for 23-h Stay After Surgery for Colon Cancer

Misha Sier ¹, T. T. T. Tweed¹, I. Daher, J. Nel², J. Van Bastelaar¹, J. H. M. B. Stoot¹

¹Zuyderland Medical Center, Surgery, The Netherlands, ²Zuyderland Medical Center, Anesthesiology, The Netherlands

Background: Introduction of the Enhanced Recovery After Surgery (ERAS) program has radically improved postoperative outcomes. Interest is rising to optimize and accelerate the enhanced recovery pathway (ERP). Optimal pain management is a crucial factor to enhance recovery. Spinal anesthesia has been introduced to decrease the postoperative pain and the need for analgesia, and to facilitate mobility. The aim of this study was to investigate the effects of spinal anesthesia with bupivacaine (Marcain) versus prilocaine prior to surgery for colon carcinoma in an accelerated enhanced recovery pathway (ERP).

Methods: This single-center, non-randomized, prospective study was carried out in one large teaching hospital in the Netherlands. The study was conducted among patients included in the CHASE study, which included patients (≥ 18 years ≤ 80) undergoing elective laparoscopic surgical resection for colon carcinoma, and meeting the following criteria: BMI ≤ 35 kg/m2, ASA I-II, available ambulant care and available by phone. The 23-h accelerated ERAS protocol consisted of a multidisciplinary and multifaceted protocol adjusting the pre-, peri- and postoperative care. Optimal pain management was one of the key elements. Based on inclusion number, patients received spinal anesthesia with prilocaine or Marcain.

Main study parameters/endpoints: The primary endpoint of this study was the Visual Analogue Score (VAS) for pain postoperatively. Secondary endpoints are reported pain scores at the surgical ward and administration of analgesia, complication rates and Length of hospital Stay (LOS).

Current status: To date 89 patients were eligible for inclusion, of whom 64 patients were included in this study, with > 80% success rate for 23-h stay after surgery. Six patients were excluded; two patients due to conversion to an open procedure, three patients due to deviation from the anesthesia protocol, and one patient due to difference in surgical procedure. Thirty-one patients received spinal anesthesia with prilocaine, 17 patients received spinal anesthesia with Marcain. Thirty patients from the prilocaine group will be compared to 30 patients in the Marcain group. We expect to have results ready within three months from now in order to present the results on the congress.

COLORECTAL—Malignant

P036—Urinary Volatile Organic Compound Testing to Aid Triage for Flexible Endoscopy in Fast-track Patients with Suspected Colorectal Cancer

Florentia Vlachou ¹, N.K. Francis², C.E. Boulind², O. Gould³, B. de Lacy Costello³, J. Allison², P. White³, P. Ewings⁴, N.J. Curtis²

¹Queen Mary University of London, Barts and the London School of Medicine and Dentistry, United Kingdom, ²Yeovil District Hospital NHS Foundation Trust, Department of General Surgery, United Kingdom, ³University of the West of England, Institute of Bio-Sensing Technology, United Kingdom, ⁴Southwest NIHR Research Design Service, Somerset NHS Foundation Trust, United Kingdom

Background: Colorectal symptoms are common but only infrequently represent serious pathology including colorectal cancer (CRC). A large number of invasive tests, such as colonoscopy, are presently performed despite a relatively small rate of CRC detection. We investigated the feasibility of urinary volatile organic compound (VOC) testing as a potential triage tool for flexible endoscopy in patients fast-tracked for assessment for possible CRC.

Methods: A prospective, multi-centre, observational feasibility study was performed across three sites. Patients referred on NHS fast-track pathways for potential CRC provided a urine sample which underwent Gas Chromatography Mass Spectrometry (GC-MS), Field Asymmetric Ion Mobility Spectrometry (FAIMS) and Selected Ion Flow Tube Mass Spectrometry analysis (SIFT-MS). Patients underwent colonoscopy and/or computed tomography (CT) colonography and were grouped as either CRC, adenomatous polyp(s) or controls for the diagnostic accuracy exploration of VOC output data. An artificial neural network (ANN) was used in the analsyis and developed using samples from 70%of the cohort, then tested on the remaining samples.

Results: 558 patients participated with 23 (4.1%) CRC diagnosed. Fifty nine percent of colonoscopies, and 86% of CT colonographies showed no abnormalities. Use of VOC testing was feasible and applicable within the clinical fast track pathway, and patient feedback supported the acceptability of the testing method. GC-MS showed the highest clinical utility for CRC and polyp detection vs. controls (sensitivity = 0.878, specificity = 0.882, AUROC = 0.884).

Conclusion: Urinary VOC analysis is feasible as a triage tool in fast-track health services pathways, and acceptable to patients. Clinically meaningful differences between those with cancer, polyps or no pathology can be detected. This route of non-invasive testing may have future utility as a triage tool to reduce the need for colonscopy of patients presenting with colorectal symptoms.

COLORECTAL—Malignant

P037—Colonic Polyps Surveillance and Outcomes—Are We Using a Magnifying Glass?

Balaji Jayasankar ¹ , K. Abdelsaid¹, D. Balasubramaniam¹, K. Frowde¹, E. Galloway¹, L. Leeves¹

¹Maidstone and Tunbridge Wells NHS England, General Surgery, United Kingdom

Aims: Colonoscopic polypectomy is a well established screening and surveillance modality for malignant colorectal polyps. Following a detection of a malignant polyp patients are either put on endoscopic surveillance or planned for a surgical procedure. We studied the outcome of colonoscopic excision of malignant polyps and their outcomes.

Methods: We performed a retrospective analysis of patients over a period of 5 years who underwent colonoscopy and resection of malignant polyps. Size of polyp, follow up with tumour markers, CT scan and biopsy were considered individually for pedunculate and sessile polyps. The main outcome was to look at the percentage of patients who underwent surgical resection, the percentage of patients who were managed conservatively and the percentage of recurrence post excision. We also identified 5 year outcome of completely removed malignant polyps in accordance with the Maastricht guidelines.

Results: The study was a retrospective analysis of 46 patients from 2015 who underwent colonscopic resection of malignant polyps. The male:female ratio of 1.4:1. 9% (4/44) of the patients went on to have a surgical resection of the malignant part and another 9% (4/44) had a trans-anal procedure for resection; 82% (36/44) were managed successfully by conservative follow up with colonoscopy, radiology and tumour markers.

Conclusions: Colonoscopic polyp resection may prove to be beneficial by avoiding a major resection. A reduction in the frequency and the battery of surveillance may be considered looking at the number of recurrence and surgical intervention.

COLORECTAL—Malignant

P038—Short-term Results of LAPRA-TY® Suture Reinforcement for Double Stapling Technique Anastomotic Reconstruction in Left-Sided Colorectal Cancer

Kobayashi Toshinori ¹ , H. Miki¹, M. Hamada¹, M. Sekimoto¹

¹Kansai Medical University, Department of Surgery, Japan

Aims: Suture failure is a serious complication in colorectal cancer surgery, with a reported incidence of 1-30%, increasing as the anastomosis becomes more distal. The cause is associated with various factors, including surgical technique and instruments, and patient factors. Recently, tissue perfusion assessment using indocyanine green (ICG) has improved safety. However, suture failure due to diarrhea in the early postoperative period still arises. In this study, we present a surgical technique preventing suture failure after double stapling technique (DST) anastomosis using horizontal mattress suture reinforcement and LAPRA-TY® Suture Clip at four points on the left and right anterior and posterior walls.

Methods: From December 2019 to August 2021, 24 patients underwent laparoscopic resection and reconstruction at our institution for primary left-sided colon and rectal cancer stage 1-3 without temporary colostomy placement and DST anastomosis. The following were the patients’ characteristics (median [range]): sex: male 17/female 7; age: 70.5 years [4789]; BMI: 25.2 kg/m2 [18.8-45.7]; ASA: 1/2/3:3/17/4; distance from anal verge: 23 cm [15-40]; tumor size: 40 mm [0-90]; pT1b/2/3/ 4: 4/3/14/3; pN0/N1/N2: 18/4/2; and two combined resection (large reticulum, partial cystectomy) and simultaneous resection cases (right hemicolectomy). Surgical technique: Following DST anastomosis, the reconstructed intestine was clamped, and the leak test was performed using transanal air delivery (50 mL catheter tipped syringe); air leak cases were considered positive. After the test, the positive left and right staple intersections, and the anterior and posterior walls, were sutured and reinforced with horizontal mattress sutures and LAPRA-TY® Suture Clip in the serous muscle layer, respectively, a transanal decompression round tube was placed after.

Results: Operative time: 215 min [123-514], blood loss: 15.5 [0-113], three cases underwent splenic flexure, intraoperative ICG evaluation: 11 cases (46%), DST staple: 60 mm in 21 cases/60 + 45 mm in three cases, circular autoanastomosis: 25 mm in 20 cases/28 mm in four cases, and post anastomosis leak test was positive in two cases, with 3-days postoperative time to resume eating [2-6]. On a postoperative day 2-3, the patients were evaluated for radiological leakage (RL) with rectal fluoroscopy study and CT scan, no RL cases were found. Duration of stay was 7 days [639], Clavien-Dindo 0/2:23/1 with bleeding balloon injury in the urethra, while one patient required blood transfusion.

Conclusion: Suture reinforcement of the DST anastomosis after ICG assessment can result in safer surgical outcomes by assessing blood flow and anastomotic strength.

COLORECTAL—Malignant

P039—Comparison of Laparoscopic vs Open Resection for Colorectal Cancer in Patients with Liver Cirrhosis

Dan Mihai Breb ¹ , T. C. Broasca¹, F. Graur¹, L. Furcea¹, E. Mois¹, F. Zaharie¹, C. Popa¹, I. C. Puia¹, N. Al-Hajjar¹

¹Regional Institute of Gastroenterology-Hepatology Prof. Dr. Octavian Fodor, General Surgery, Romania

Aims: Colorectal surgery in patients with liver cirrhosis represents a challenge because of its association with a higher morbidity and mortality rate. The aim of this study is to determine the benefits of choosing a minimally invasive surgical approach.

Methods: The patients with liver cirrhosis that underwent colorectal cancer resection were identified retrospectively from our hospital database and were grouped by the technique used, laparoscopic and open resection. We compared the two groups for short and long-term results.

Results: Upon comparison of the two groups, laparoscopic and open, there were no remarkable variations. The laparoscopic group showed a faster recovery rate, fewer days of hospitalization, and reduced blood loss during the intervention. The morbidity rate was lower in the minimally invasive group but the long-term overall survival rate was the same in both groups.

Conclusion(s): In some selected cases the laparoscopic approach for colorectal cancer resections in patients with liver cirrhosis may benefit from lower morbidity rates and less blood loss but the long-term overall survival did not seem to vary.

COLORECTAL—Malignant

P040—The Usefulness of TaTME for Low Anterior Resection for Frail Patients in Exclusive Spinal and/or Epidural Anaestyhesia

Simone Maria Tierno ¹ , F. Stipa¹

¹Madre Giuseppina Vannini Hospital, Department of Surgical Oncology, Italy

Purpose: Invasive rectal cancer is predominantly a disease of older adults with a high likelihood of suffering from concomitant diseases. In these patients, the risks associated with general anaesthesia during radical proctectomy can be the limiting factor of performing an otherwise indicated radical and minimally invasive procedure. To overcome this limitation, we analysed the feasibility of performing a trans-anal total mesorectal excision with disposable platform in exclusive spinal and/or epidural anaesthesia.

Methods: Between January 2020 and December 2021, five patients underwent low anterior resection with trans-anal total mesorectal excision (TaTME) in exclusive spinal and/or epidural anaesthesia. These patients were unfit to undergo radical procetectomy in general anaesthesia. Patient were male with a bulky low rectal cancer. All underwent neoadiuvant chemioradiotherapy 8 weeks before surgery. Using a GelPoint path trans-anal platform, the rectum and mesorectum was fully mobilized until the peritoneal reflection was reached. A purse string suture is fashioned to close the distal rectal stump. The abdominal part was accomplished through a small Pfannesteil incision with ligation of the mesenteric artery and dissection of the left colon between the Toldt’s and Gerota’s fascia.

Results: All five procedures could be performed under strict regional anaesthesia. Mean BMI was 29, mean operation time was 133 min (range 90-142 min), mean postoperative time at intermediate care was 1 day (range 0-3 days) and mean length of hospital stay was 12.8 days (range 7-16 days). Three of five patients suffered of minor complication according to Clavie Dindo Classification.

Conclusion: Performance of low anterior resection in exclusive spinal and/or epidural anaesthesia following optimal oncologic outcomes is feasible. TaTME is a usufllness techinique which combines mini-invasive surgery and correcto oncological principle for low rectal cancer particularly in those patients who would be otherwise unfit to undergo radical procetectomy in general anaesthesia.

COLORECTAL—Malignant

P041—A New Classification for the Branching Pattern of the Left Colic Artery and the Sigmoid Arteries from the Inferior Mesenteric Artery

Airazat M. Kazaryan ¹, B.T. Andersen¹, B.V. Stimec², B. Edwin³, P. Rancinger¹, D. Ignjatovic⁴

¹Østfold Hospital Trust, Department of Gastrointestinal Surgery, Norway, ²University of Geneva, Anatomy Sector, Switzerland, ³Oslo University Hospital—Rikshospitalet, Intervention Centre and Department of HPB Surgery, Norway, ⁴Akershus University Hospital, Department of Gastrointestinal Surgery, Norway

Aims: The splenic flexure is situated in-between two vascular areas irrigated from the middle colic artery (MCA) and from the inferior mesenteric artery (IMA). The aim of this study is to explore the impact of the MCA bifurcation, the presence of the accessory middle colic artery (aMCA), the 3-dimensional relationship between the two vascular areas and the pattern of the inferior mesenteric vein (IMV) confluence.

Methods: The vascular anatomy was studied using 32 preoperative high-resolution CT scans. The CT scans were manually 3D reconstructed using Osirix MD, Mimics Medical and 3-matic Medical Datasets, and exported for further investigations as PDF files, video clips, stills and STL files for 3D printing.

Results: The most common position (53.1%) for the MCA bifurcation was in front of the superior mesenteric vein (SMV), followed by right to SMV (34,4%) and left to SMV (12.1%). The median distance from the MCA origin to the MCA bifurcation was 3.21 cm. The aMCA was found in 31.3% of the patients. All aMCA trajected towards the splenic flexure. 50% directly through the transverse colon mesentery, and 50% following the lower pancreatic border before turning towards the flexure. The origin of MCA could be found both cranial (87.5%) and caudal (9.4%) to the origin of IMA. 3.1% of the patients lacked proper MCA. We found an anatomical triangle between the MCA origin, the aorta, and the IMA origin. This triangle represents the mesenteric inter-arterial step. The IMV has two main confluence patterns, to the SMV, either through a jejunal vein or directly (65.6%) or to the splenic vein (34.4%). Either way, the path of the IMV could be infrapancreatic (53.1%), infrapancreatic with a retropancreatic arch (21.9%) or true retropancreatic (25%).

Conclusion: Today the surgeon could be aided by many techniques giving the possibility to personalise surgery according to patient specific anatomy. The different anatomical variants might represent different possible lymphatic pathways which must be considered. To negotiate the mesenteric inter-arterial step, the surgeon could follow the IMV.

COLORECTAL—Malignant

P042—A Comparative Analysis in laparoscopic Surgery in Young vs. Old Patients with Colorectal Cancer

Tudor-Calin Broasca ¹, D. M. Breb¹, F. Graur¹, L. Furcea¹, E. Mois¹, F. Zaharie¹, C. Popa¹, I. C. Puia¹, N. Al-Hajjar¹

¹Regional Institute of Gastroenterology and Hepatology Prof. Dr. Octavian Fodor, General Surgery, Romania

Background: The laparoscopic technique in patients with colorectal cancer tends to overtake the classical open approach, even though in locally advanced tumors this issue is still in debate. The aim of this study is to determine if there is any difference in mortality rates, benefits, postoperative complications as well as long-term survival between the group of young and elderly patients.

Methods: We have collected data from patients < 40 years old and > 40 years old that underwent elective laparoscopic surgery for colorectal cancer, between 2016-2021 at the department of general surgery in Cluj—Napoca. The characteristics of the population, tumor, and surgical aspects were retrospectively analyzed for short-term and long-term results.

Results: The results showed us that in the group of elderly patients there seems to be a significantly higher rate of surgical conversion as well as postoperative mortality. Local and distant recurrence did not differ between the two groups. There has not been found any difference in terms of tumor aspects, surgery duration. Younger patients seem to have been used adjuvant chemotherapy more frequently than older patients. Overall survival seems to be lower in the group of elderly patients compared to the young ones.

Conclusion: Minimally invasive surgery seems to be a strong option in the treatment of colorectal cancer in both young and old patients even though there is a significantly higher rate of conversion and postoperative mortality in the elderly group, which may influence the long-term outcomes.

COLORECTAL—Malignant

P043—Evaluation of Our Medial Approach and Mesenteric Resection Range by ICG in Transverse Colon Cancer

Tatsuya Kinjo ¹ , Y. Miyagi¹, M. Takatsuki¹

¹University of the Ryukyus, Department of Digestive and General Surgery, Japan

Introduction: Since the vessels of the transverse colon are often anatomically exceptional and is embryologically the boundary between the midgut and the hindgut, the approach method and the appropriate lymph node dissection range have not yet been standardized. We perform dissection based on the medial approach using the evaluation of lymphatic flow around the tumor by ICG.

Aim: We investigated lymph node metastasis in transverse colon cancer and procedures of our medial approach and dissection range determination method.

Patients: Twenty-five cases of primary transverse colon cancer who underwent transverse colon resection between 2010 and December 2020.

Procedures: ICG was injected around the tumor. The Ileocecal region to hepatic curvature was detached for hepatic-sided cancer, or IMV medial to spleen curvature was detached for splenic-sided cancer. Next, we determined whether hemicolectomy or partial resection according to lymphatic flow. The following procedures were performed along the surface of the transverse retrocolic space (TRCS). The MCA or either branch was resected for D3 resection. After entering the side of the omental bursa in transverse colon mesentery, complete mesenteric excision (CME) was performed from the layer of the pancreatic head-duodenum plus the adipose tissue including subpyloric lymph nodes along to the surface of the TRCS. Lastly, the remaining another side of mesentery and colon dissection was performed, and CME was completed only with the medial approach.

Results: Age 72 years (54-86), male/female: 16/9, open/laparoscopy = 9/16. pStage I/IIa/IIb/IIIb/IIIc = 6/12/3/3/1. Right hemicolectomy in 5 cases, transverse colon resection in 17 cases, and left hemicolectomy in 3 cases. There were 2 recurrences, 1 was a recurrence of # 223 metastasis in a D2 dissection case.

Conclusion: It was considered that mesenteric dissection without excess or deficiency was possible by medial approach and observing lymphatic flow by ICG.

COLORECTAL—Malignant

P044—Colorectal Surgeries in Public Sector Hospital in Low Socioeconomic Coutry. Our Experience and Lessons Learned

Suleman Asif ¹ , U. Kafeel¹, A. Amjad¹, A. Autangzaib¹

¹Lahore General Hospital Lahore, Surgical Oncology, Pakistan

Objective: To share our experience of the colorectal cancer surgeries in public sector hospitals.

Methods: All cases from Jan 2018 to Dec 2021 were included. Patient demographics, area of presentation (Emergency, Elective), type of surgery with complications, adjuvant or neo adjuvant treatment were all recorded.

Results: 36 months. 125 cases. 46 colon cancers and 59 cases of rectal cancer. 101 patients operated. 4 undergoing neoadjuvant chemo radiation. 23 cases operated in emergency, 78 in elective setting. 42 laparoscopic (3 converted), 59 open. 2 re-explorations. Two mortalities. Both Ca colon presenting with intestinal obstruction. 20% of patients presented with obstruction and delayed presentation despite having visits to different hospitals where a diagnosis couldn’t be made. Only 31 cancer cases were discussed in our hospitals tumor board meeting.

Conclusion: Its time to start a dedicated colorectal services in public sector hospital to improve patient referral and reduce delays in presentation and improving outcomes.

COLORECTAL—Malignant

P045—Simultaneous Laparoscopic Resection of Primary Colorectal Cancer and Synchronus Liver Metastases: Initial Experience of Single Institute

O. Kvasivka¹, Inesa Huivaniuk ¹, A. Beznosenko², K. Kopchak¹, I. Huivaniuk¹

¹National Cancer Institute, HPB, Colorectal, Ukraine, ²National Cancer Institute, HPB, Ukraine

Background: Synchronous presentation of liver metastases at the time of diagnosis of the primary tumor occurs in approximately 20% of patients and is associated with worse clinical outcomes. Metastatic liver tumors are resectable in 10 to 20% of cases. Simultaneous primary cancer and liver metastases resection is a treatment of choice in selected patients. The aim of this report was to present our initial experiences of simultaneous surgery performed laparoscopically.

Methods: A single-center, retrospective report of 8 cases of laparoscopic simultaneous resection of colorectal cancer and liver metastases was carried out.

Results: The average patients` age was 60 years old (range, 35–74 years) and average body mass index was 28.2 kg/m2 (range, 26.3–30.0 kg/m2). The primary tumor was right-sided colon in 2 cases, left-sided colon in 4 cases, and rectal cancer in 2 cases. 6 patients presented with single-lesion liver metastasis and 2 patients presented with two lesions metastases, the majority of metastatic tumors were subcapsular. The mean operating time was 303 min (range, 130–500 min) and blood loss was 340 mL (range, 150–500 mL). The mean hospital stay was 7.5 days (range, 5–11 days). One patient developed delayed gastric emptying grade A and one patient developed biloma, which was not clinically significant.

Conclusions: This report shows that simultaneous laparoscopic resection of primary colorectal cancer and liver metastases is safe, technically feasible in selected patients and has a high cost-effectiveness.

COLORECTAL—Malignant

P046—Endoscopic Transmural Drainage of Postoperative Intra-abdominal Abscesses

Mateusz Jagielski ¹ , Ł. Bereziak¹, J. Piątkowski¹, M. Jackowski¹

¹Collegium Medicum, Nicolaus Copernicus University, Department of General, Gastroenterological and Oncological Surgery, Poland

Aims: Currently, endoscopic transmural drainage is a common method of treatment of post-inflammatory pancreatic fluid collections. Use of endoscopic ultrasonography in transmural drainage makes access through the wall of gastrointestinal tract to other pathological fluid collections possible, including postoperative intra-abdominal abscesses (PIAAs). Assessment of usefulness of endoscopic transmural drainage in treatment of PIAAs.

Methods: Retrospective assessment of endotherapy results’ in all 29 patients with PIAAs in years 2018-2021 in the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland. Patients were divided into two groups depending on period between the surgery and beginning of endoscopic treatment. The 1.group consisted of patients who underwent endoscopic transmural drainage of PIAAs during first two weeks after the surgery. The 2.group consisted of patients in whom endotherapy began two weeks after the surgery or later.

Results: In all 29 patients active transmural (transgastric) endoscopic drainage through single approach was performed. The 1.group consisted of 16/29 (55.17%) patients with PIAAs, the 2.group consisted of 13/29 (44.83%) patients with PIAAs. In both groups PIAAs were complications of urgent laparotomy due to purulent or fecal peritonitis caused by pathology in the large intestine (81.25% vs 76.92%, p = NS). The active transmural endoscopic drainage lasted 7 (5-12) days in the 1.group and 13 (7-22) days in the 2.group (p < 0.05). Complications of endotherapy were stated in 3/16 (18.75%) patients in the 1.group and in 2/13 (15.38%) patients in the 2.group (p = NS). Clinical success was achieved in 15/16 (93.75%) patients from the 1.group and in 10/13 (76.92%) patients from the 2.group (p = NS). Long-term success was stated in 14/16 (87.5%) from the 1.group and in 9/13 (69.23%) patients from the 2.group (p < 0.05).

Conclusion: Endoscopic transmural drainage is an effective method of treatment of PIAAs. An early endoscopic drainage results in better outcomes of treatment in this group of patients.

COLORECTAL—Malignant

P047—Is Colorectal Cancer Surgery A New Challenge in These Troubled Moments?

Radu Mihail Mirica ¹, V. Andrei¹, D. Danut², R. Razvan², M. Marius², A. Alexandra³, M. Mara², N. Nicolae², O. Octav²

¹Emergency Clinical Hospital 'Saint John', University of Medicine and Pharmacy ' Carol Davila', Bucharest, General surgery, Romania, ²Emergency Clinical Hospital 'Saint John', Bucharest, General surgery, Romania, 3 Emergency Clinical Hospital 'Saint John', Bucharest, General surgery, Romania 4 Emergency Clinical Hospital 'Saint John', Bucharest, General surgery, Romania, ³Emergency Children Clinical Hospital 'Grigore Alexandrescu', Bucharest, Endocrinology, Romania

Introduction: Colorectal cancer is the most common malignant surgical pathology of the digestive tract that presents great interest. The SARS-COV2 pandemic has caused many difficulties in the management of patients with colorectal cancer, difficulties that required a relatively quick solution so that patients with this pathology are not deprived of the best possible care.

Aim: The aim of this study was to identify the differences encountered during the SARS-COV2 pandemic compared to the previous period in terms of the difficulty of the cases and their management, therefore being able to make changes in the essential points of treatment of these cases.

Materials and methods: The case study of the Surgery Clinic of the Emergency Clinical Hospital ‘Saint John, Bucharest’ was analysed comparatively between February 2019—January 2020 and February 2020—January 2021 (SARS-COV2 pandemic period).

Results: The study included 423 patients 119 during COVID pandemic and 304 between February 2019 and January 2020. Descriptive statistics show a similar breakdown by sex, area of origin and number of days of hospitalization. The decade of age with maximum incidence being higher in the period 2019–2020. The differences were in the case of the number of surgeries resulting in colostomy, respectively the percentage of cases in advanced stages that occurred during COVID. The percentage of cases presented in the emergency was also higher during the COVID period. During this period, the number of cases was partially correlated with the incidence of positive COVID cases.

Conclusions: The SARS-COV2 pandemic has underlined different difficulties in the management of colorectal cancer patients. The most important one is that patients presented to the hospital in much more advanced stages during this period. Therefore, we were able to offer very limited treatment options.

COLORECTAL—Malignant

P048—Short and Long-Term Outcomes of Single Incision Laparoscopic Surgery for Right-Side Colon Cancer

Taishi Hata ¹ , R. Ikeshima¹, K. Kawai¹, M. Hiraki¹, Y. Katsura¹, Y. Ohmura¹, K. Sugimura¹, T. Masuzawa¹, Y. Takeda¹, K. Murata¹

¹Kansai Rosai Hospital, Surgery, Japan

Background: There is little data concerning the long-term outcome of single incision laparoscopic surgery (SILS) for colon cancer. Therefore, we investigated not only the short-term outcomes but also the long-term outcomes of SILS for right-side colon cancer. There were 290 operations conducted for right-side (Cecum and Ascending) colorectal cancers from April 2011 to July 2018. 12 patients planned laparotomy. Of the remaining 278 patients, 55 patients planned conventional laparoscopic surgery, 27 patients planned Reduced poet surgery (RPS) and 196 patients planned SILS respectively. The procedure had been selected by skilled surgeons. One patient underwent intraoperative conversion from SILS to laparotomy for bleeding control. In addition, one port was added to SILS in three cases. These four cases were included in the analysis as SILS group according to the principle of intent to treat. Background factors, including age, gender, body mass index, performance status, and tumor stage were not statistically different between the SILS and CLS groups. In short-term outcomes, the number of harvested lymph-nodes was not statistically different. SILS required less operating time (P < 0.001) and resulted in a reduced bleeding volume (P < 0.001). There was no statistical difference in the frequency of overall complications (P = 0.06). The disease-free survival of stage 0 to III patients was not statistically different between the two groups.

Conclusions: Skilled surgeons can achieve adequate oncologic long-term outcomes in selected subgroups of SILS patients. Therefore, SILS could be a treatment option for right-sided colon cancer.

COLORECTAL—Malignant

P049—Impact of Colorectal Cancer Screening Programme On Colonic Cancer Surgery Outcome In Our Institution

Mohamed Salama ¹, M. Khalifa², A. Gadura³, A. Graviscow³, I. Ahmed³

¹Our Lady of Lourdes Hospital, General Surgery, Ireland, ²Trinity College Dublin, School of Medicine, Ireland, ³NUI Galway, School of Medicine, Ireland

Introduction: Over the past 3 decades the number of Colorectal Cancer (CRC) cases has significantly increased in Ireland. Despite considerable improvement in CRC management, there is a great deal of variation of outcomes among European countries and particularly among different hospitals.

Aims: To evaluate the impact of CRC screening programme on patient outcome after CRC surgery in our institution.

Method: We conducted a retrospective cohort study including all patients with CRC treated at our institution between 2013 and 2018. Patients were classified into 3 subgroups: 1) Age ≤ 50 years 2) Age > 50 and < 75 years 3) Age ≥ 75 years

Data collected: age, gender, location, stage, operation and histology.

All patients were followed for prognosis and mortality.

Results: Total number: 342 (F:141, M:201), age range: 30-96y. Group 1: 29 (F:7, M:22), Group 2: 177 (F:65, M:112), Group 3: 136 (F:51, M:85). Tumour Location: Left: 166, Right: 176

4 patients underwent palliative treatment (3 advanced stage, 1 elderly). 29 patients (8.5%) underwent emergency surgery secondary to obstruction or perforation. (F: 14, M: 15) Age range: 41-93y.

With respect to tumour stage, 93% of Group 1, 91% of Group 2 and 86% of Group 3 presented with stage 3 or more.

Regarding the mortality: Follow-up showed that 87 out of 342[F:31 (35.6%), M:56 (64.4%)] died with a mortality rate of 25.4%. Mortality in age group 1 was 3(10.3%), group 2 was 48(27.1%) and group 3 was 36(26.4%).

Conclusion: In our study, most of the cases were diagnosed at late stage (Stage 3 and 4). This is likely to be as a result of more comprehensive investigation in the perioperative period, resulting in a significant shift in stage allocation from stage 1 and 2 to stage 3 and 4.

The bowel screening programme in Ireland includes individuals aged 60 to 69 years. This narrow age range means that the potential benefits of screening in terms of early detection of CRC and reduction in incidence and mortality are unlikely to be achieved in the short term.

Although Irish survival has improved, it remains below the European average

COLORECTAL—Malignant

P050—Small Bowel Obstruction Caused by Intestinal Metastases of Bilateral Metachronous Lobular Breast Cancer: A Case Report and Literature Review

Mohamed Salama ¹, A. Salama², F. Kazi³, B. Sami³, A.R. Nasr³

¹Our Lady of Lourdes Hospital, General Surgery, Ireland, ²Trinity College Dublin, School of Medicine, Ireland, ³Our Lady of Lourdes Hospital, General Surgery, Ireland

Introduction: Breast cancer (BC) is a leading cause of cancer death worldwide. Metastases to the gastrointestinal tract (GIT) from breast cancer are seldom recognised in the clinical setting and its true incidence is unknown. Although breast cancer metastases to small intestine are extremely rare, it has been increasingly reported as an uncommon cause of intestinal obstruction.

Case report: A 76 year old lady with recurrent presentations for abdominal pain, nausea, vomiting and weight loss, on a background of abdominoperineal resection and chemoradiotherapy for rectal adenocarcinoma 9 years ago, and Right mastectomy, hormonal therapy and chemoradiotherapy for lobular BC 31 years ago with good surveillance. CT confirmed small bowel obstruction likely adhesive with transition point at the jejunum. Emergency laparotomy was performed and showed a stenotic mid-jejunal area which was resected with end-to-end anastomosis. Histology confirmed metastatic lobular carcinoma in keeping with previous breast cancer. Examination of left breast during this admission revealed a new, firm mass suggesting metachronous malignancy. She was referred to the breast service and biopsy confirmed lobular carcinoma.

Conclusion: BC metastases to GIT are rare and occur more frequently in invasive lobular carcinoma. As the prognosis of BC continues to improve with modern medical practice, it is important to be aware of clinical presentations and appropriate management of BC metastases. The time interval between primary and GIT metastases may range from synchronous presentations to as long as 31 years as in this case. GI manifestation may precede BC diagnosis. The early diagnosis of bowel metastases from BC is quite challenging (very rare, non-specific clinical and radiological manifestation, long disease free interval). No consensus exists on treatment of GIT metastases from BC.

COLORECTAL—Malignant

P051—Coexistence of Anorectal Malignant Melanoma and Right Colon Metastatic Melanoma: A Case Report and Literature Review

Mohamed Salama ¹, A. Salama², W. Shabo¹, A. Nasr¹

¹Our Lady of Lourdes Hospital, General Surgery, Ireland, ²NUI Galway, School of Medicine, School of Medicine, Ireland

Introduction: Anorectal malignant melanoma is an extremely rare, aggressive tumour with grave prognosis, accounting for 0.4-1.6% of all melanomas and 0.5-4.6% of anorectal malignant tumours. Moreover, coexistence of anorectal melanoma and right colon metastatic melanoma is rarer and not previously reported. We report a case of anorectal malignant melanoma synchronous with right colon metastatic melanoma and metastatic right groin lymph node melanoma hoping our case can contribute to the existing literature.

Case report: A 77 year old male on a background of chronic kidney disease presented with lower abdominal pain for a week, associated with nausea, weight loss and anorexia. On examination, he was tender in the right iliac fossa and suprapubic region and there was a right groin mass, query femoral hernia/ lymph node. His laboratory findings reported CRP of 101, WCC 7.6, LDH 610, lactate 3.6, deranged Urea and creatinine and normal LFTs. CT abdomen and pelvis with contrast reported diffuse lymphadenopathy, bilateral adrenal masses and a soft tissue mass deep within the pelvis and perineum extending to involve the prostate, seminal vesicles, mesorectum fascia and rectum. Colonoscopy up to caecum showed an anorectal black ulcerative lesion along with a right colon ulcerating mass, which were biopsied and right groin lymph node was excised. Histology reported metastatic right groin lymph node melanoma and metastatic malignant melanoma of the right colon and anorectal malignant melanoma. Thorough physical examination revealed no other ocular or mucocutaneous lesions. The case was discussed at the Oncology MDT and referred for palliative chemotherapy.

Conclusion: Synchronous anorectal melanoma and right colon melanoma is extremely rare and not reported previously. The right colon melanoma found in this case is thought to be a secondary rather than a primary. The presence of primary melanoma of the colon has been questionable since there are no melanocytes in the colon. GI melanoma is a challenging diagnostic entity that requires a thorough investigation to determine if it is a true primary lesion or metastatic.

COLORECTAL—Malignant

P052—Laparoscopic Operations in Patients with Profuse Bleeding from Tumor of Small Intestine

Yurii Grubnik ¹ , V. Fomenko¹, O. Yuzvak¹, M. Grubnik¹

¹Odesa National Medical University, Surgery Department, Ukraine

Aim: Reducing mortality and postoperative complications by performing laparoscopic operations in patients with profuse bleeding from tumor of small intestine.

Methods and materials: Over the past 3 years, 1865 patients with bleeding from the gastrointestinal tract have been admitted to the clinic. Out of them, 1176 patients with bleeding from the stomach and duodenum. In 681 patients, bleeding is caused by the pathology of the large intestine. In 8 patients, video endoscopy did not reveal a source of bleeding from the stomach and duodenum. Colonoscopic examination of the rectum and colon did not reveal the source of bleeding from the large intestine. In 5 patients profuse bleeding was repeated during their stay in the department. In 6 cases, the patients underwent CT with intravenous injection of a contrast agent. In 2 cases, CT scan with contrast was not performed due to high levels of urea and creatinine. In that cases was performed examination of the small intestine using the intraluminal capsules.

Results: Out of 8 patients, GIST was detected in 5 cases. Laporoscopic resection of the small intestine was produced with further performing enteroenteral anastomoses. Due to histological examination of malignant cells in the tumor and lymph nodes were not found. In 3 cases, laparoscopic resection of the small intestine was also performed for intestinal adenocarcinoma with lymph node dissection. In 1 patient, the postoperative period was complicated by an intra-abdominal abscess, which was drained under ultrasound control. There were no lethal cases.

Conclusions: Laparoscopic surgery reduces blood loss, postoperative complications and mortality.

COLORECTAL—Malignant

P053—Laparoscopic Colorectal Resection with Intracorporeal Delta Anastomosis in Reduced Port Surgery Utilizing an Incision at the Umbilicus

Hiroki Yonezawa ¹ , Y. Hirano¹, S. Shimamura¹, A. Kataoka¹, M. Sasaki¹, T. Fujii¹, N. Okazaki¹, S. Ishikawa¹, T. Ishii¹, K. Deguchi¹

¹Saitama Medical University International Medical Center, Gastroenterology Center, Japan

Introduction: Minimally invasive surgery has become popular for colorectal cancer, and we have introduced reduced port surgery for less invasive surgery. In recent years, there has been a growing interest in fully laparoscopic colorectal resection, in which intestinal dissection and anastomosis are performed intracorporeally. Intracorporeal anastomosis has been reported to shorten the length of the small laparotomy wound, reduce the risk of vascular injury during anastomosis, and allow early recovery of bowel function, but there are not many reports on reduced port surgery.

Aims: We report two cases of reduced port laparoscopic colectomy for colon cancer using intracorporeal anastomosis with Delta anastomosis, including a video of the surgery.

Methods: Case 1: A 61-year-old man. He underwent a single-incision plus one-port laparoscopic right hemi-colectomy for T2N0M0 Stage I ascending colon cancer. Operative time 210 min, blood loss 23 ml. Case 2: A 79-year-old man. He underwent a single-incision plus two-port Senhans-assisted laparoscopic right hemicolectomy for T3N1bM0 Stage IIIB ascending colon cancer.

Results: Case 1: After radical resection of the tumor, an intracorporeal Delta anastomosis was performed with single-incision plus one port by inserting a stapler through a multichannel device in the umbilical region for reconstruction. The patient started eating from POD3 without any postoperative complications and was discharged from the hospital on POD6. Case 2: As in case 1, after radical resection of the tumor, a stapler was inserted through a multichannel device in the umbilical region, and an intracorporeal Delta anastomosis was performed with Senhance-assisted reduced port laparoscopic surgery. The patient started eating from POD3 without any postoperative complications and was discharged on POD6.

Discussion: It has been reported that intracorporeal anastomosis can shorten the length of a small laparotomy wound, and combining it with reduced port surgery, a minimally invasive technique, may further reduce invasiveness. In addition, since the scope and stapler enter from the same single-incision, the angle of stapler insertion is easier to match, and excessive tension on the intestinal membrane may be reduced.

Conclusion: Laparoscopic colon resection with intracorporeal Delta anastomosis in reduced port surgery using an umbilical incision was performed safely and comfortably. Further studies are needed to accumulate more cases.

COLORECTAL—Malignant

P054—Transanal Total Mesorectal Excision (TaTME) for Low Rectal Cancer—Our Experience

Nikolaos Georgopoulos ¹ , N. Tasis¹, Chr. Barkolias¹

¹Athens Naval and Veterans Hospital, Surgical Department, Greece

Aim: The transanal total mesorectal excision (TaTME) is a valuable and relatively new technique for low rectal cancer surgery. It consists of a conjoined standard laparoscopic low anterior resection and the transanal endoscopic approach. In this poster we describe our first five TaTMEs of our surgical department with emphasis in the surgical technique and postoperative and oncological outcomes.

Methods: Five patients (2 males and 3 females) with average age 47,8 years (24 to 60) underwent laparoscopic TaTME due to very low rectal cancer in four patients and due to familial polyposis in one. All patients underwent MRI for staging. All cancer patients received neo-adjuvant chemoradiotherapy with substaging of the original disease. Surgical technique, postoperative complications and oncological outcomes are decribed.

Results: Average operative time was 313 min (285 to 360 min). There was a vaginal rupture intraoperatively which was sutured laparoscopically. Postoperatively a patient suffered from left ureter stenosis which was successfully managed with a pigtail catheter. Average hospital stay was 6,2 days (5-7). Postoperative follow up included digital rectal exam, orthoscopy and abdominal CT every 6 months and colonoscopy yearly. No recurrence was observed during follow up (1–3 years).

Conclusion: TaTME in experienced hands and specialized training is a feasible and safe alternative for the management of very low rectal cancer offering sphincter conservation, low complication rates and satisfactory oncologic outcome.

COLORECTAL—Malignant

P055—Peri-operative Outcomes in Elderly Undergoing Minimally Invasive Right Hemicolectomy

Monica Ortenzi ¹, M. Milone², A. Balla³, E. Botteri⁴, M. Podda⁵, A. Sartori⁶, M. Palmieri¹, G. Lezoche¹, M. Guerrieri¹

¹Università Politecnica delle Marche, Clinica Chirurgica, Italy, ²University of Naples "Federico II", Department of Clinical Medicine and Surgery, Italy, ³Hospital “San Paolo”, UOC of General and Minimally Invasive Surgery, Italy, ⁴ASST Spedali Civili Brescia, General Surgery, Italy, ⁵University of Cagliari, Department of Surgical Science, Italy, ⁶Ospedale San Valentino—Montebelluna, U. O. Chirurgia generale e d'urgenza, Italy

Aims: Several studies demonstrate the advantages of minimally invasive colonic resections in improving short-term postoperative outcomes. However, currently, the treatment strategy for elderly patients depends on the policies of each institution. The aim of this study was to investigate the safety and feasibility of minimally invasive right hemicolectomy for patients with colon cancer aged over 75 years using a propensity score matching (PSM) model based on age and Charlson Comorbidity Index (CCI).

Materials: This was a multicenter retrospective study combining four prospectively maintained databases of consecutive patients undergoing elective right hemicolectomy between January 2013 and December 2020. The primary endpoint of the study was to analyse the short-term postoperative results of minimally invasive right hemicolectomy in elderly patients. Secondary outcomes included risk factors for complications and prolonged operative time. Patients were divided into three groups according to their age: Group I (control group, < 60 years), Group II (> 60-75), Group III (≧75), and further divided according to the operative approach: Laparoscopic (LrH) or Robotic (RrH) and Open resection (OrH). Variables baseline demographic data (gender, Body Mass Index(BMI), American Society of Anaestesiologists (ASA) grade, Charlson Comorbidity Index (CCI), comorbidities, Previous abdominal surgery, CT location, size and stage of the tumour), intra-operative data (operative time, intra-operative complications, need and causes of conversion) and post-operative course (post-operative complications, time to flatus and length of stay) were investigated. Need for readmission and 90-days mortality were also included.

Results: Of the 618 included patients, 267 (43.2%) were aged between 60 and 75 years, while 268 (43.4%) were older than 75 years, 337 (54.5) patients LrH, 144 (23.3%) RrH and 137 (22.2%) OrH. Group II and III did not differ for short term major surgical complications rate (p = 0.392), nor for general major complications (13 Vs 8; p = 0.380), nor in the length of hospital stay and readmission rate (p = 0.944 and p = 0.308 respectively). None of the post-operative parameters analyzed differed when comparing LrH and RrH. Mortality was not observed. OrH statistically differed from LrH/RrH in intraoperative complications (6 vs 1; p = 0.011) and estimated intra-operative blood loss (p = 0.001) was observed. The rate of post-operative complications was significantly higher in the OrH group (40 vs 82; p = 0.22) considering both surgical and general complications (p = 0.039 and p < 0.0001, respectively). Mortality at 90 days from the operation was observed in 5 patients (3.8%) in the OrH group. Male gender and tumour location were identified as risk factors for prolonged operative time at univariate analysis but not in the multivariate analysis. Open procedures were associated with operative time > 180 min in both univariate and multivariate analysis. Conversion to open surgery resulted as a risk factor for complication occurrence and Class III complications in both univariate and multivariate analyses. Open procedure was a risk factor for Class III only at univariate analysis.

Conclusions: These results suggest that indication for laparoscopic surgery should not be abandoned for elderly patients solely based on older age. The decision should be taken based on the individual patient condition, life expectancy, and patient’s wishes and not specifically based on patient age

COLORECTAL—Malignant

P056—Evaluation of the Anticipated Surgical Difficulties in minimally Invasive Rectal Cancer Surgery Using MRI Pelvimetry

Marcin Migaczewski ¹ , M. Rubinkiewicz¹, J. Rymarowicz¹, T. Wikar¹, M. Pędziwiatr¹

¹Medical College, Jagiellonian University, II of Gereral Surgery, Poland

Rectal cancer is the third most common cancer related cause of death in the western countries and the risk of rectal cancer is increasing with age. Total mesorectal excision (TME) which comprises excision of the tumour with the surrounding tissue is the standard operative technique frequently combined with neoadjuvant chemo- and radiotherapy. Patient’s anatomical conditions are important factors influencing the difficulty of the procedure and can limit its quality. BMI, gender, tumour size and dimensions of the pelvic cavity are well known predictive factors of surgical difficulty in patients undergoing rectal surgery.

In order to choose the best treatment strategy, it is crucial to perform preoperative magnetic resonance (MRI) of the pelvis, a „ gold standard” in diagnostic work-up of rectal cancer patients. It determines the size and location of the tumour, its invasion of the surrounding structures and the presence of enlarged mesorectal lymph nodes. MRI allows as well to perform various pelvimetric measurements which are not ordinarily used in predicting intraoperative difficulties.

Retrospective cohort study was performed which included 110 patients with rectal cancer treated either with LAR or TaTME.

The unusual aspect of our study is the comparison of two minimally invasive surgeries—LAR and TaTME in regards to predicting intra and perioperative difficulties based on preoperative pelvimetric parameters analysis based upon MRI images. There was an increased risk or postoperative morbidity depending on the puboccocygeal distance (cut-off point 136 mm) in the TaTME group whereas there was no significant association of these parameters in the LAR group. Perhaps it is worth taking into consideration this parameter in the choice of surgical approach. There were similarities in both groups in the analysis of the risk factors of intraoperative blood los. Again, in selected cases the choice of operative technique may be supported by pelvimetric parameters

MRI based pelvimetric parameters measurement can influence surgeon’s choice of a particular surgical procedure in patients with resectable rectal cancer.

COLORECTAL—Malignant

P057—Surgical Stress and Metabolic Response After Totally Laparoscopic Right Colectomy

Michele Manigrasso ¹, G.D. De Palma², M. Milone²

¹"Federico II" University of Naples, Advanced Biomedical Sciences, Italy, ²"Federico II" University of Naples, Clinical Medicine and Surgery, Italy

No clear consensus on the need to perform an intracorporeal anastomosis (IA) after laparoscopic right colectomy is currently available. One of the potential benefits of intracorporeal anastomosis may be a reduction in surgical stress. Herein, we evaluated the surgical stress response and the metabolic response in patients who underwent right colonic resection for colon cancer. Fifty-nine patients who underwent laparoscopic resection for right colon cancer were randomized to receive an intracorporeal or an extracorporeal anastomosis (EA). Data including demographics (age, sex, BMI and ASA score), pathological (AJCC tumour stage and tumour localization) and surgical results were recorded. Moreover, to determine the levels of the inflammatory response, mediators, such as C-reactive protein (CRP), tumour necrosis factor (TNF), interleukin 1β (IL-1β), IL-6, IL-10, and IL-13, were evaluated. Similarly, cortisol and insulin levels were evaluated as hormonal responses to surgical stress. We found that the proinflammatory mediator IL-6, CRP, TNF and IL-1β levels, were significantly reduced in IA compared to EA. Concurrently, an improved profile of the anti-inflammatory cytokines IL-10 and IL-13 was observed in the IA group. Relative to the hormone response to surgical stress, cortisol was increased in patients who underwent EA, while insulin was reduced in the EA group. Based on these results, surgical stress and metabolic response to IA justify advocating the adoption of a totally laparoscopic approach when performing a right colectomy for cancer.

COLORECTAL—Malignant

P058—Long-Term Oncological Results After Laparoscopic Sigmoidectomy for Adenocarcinoma

Andrea Balla ¹ , F. Saraceno¹, A. Guida¹, R. Scaramuzzo¹, G.M. Ettorre², M. Carlini³, P. Lepiane⁴

¹Hospital “San Paolo”, UOC of General and Minimally Invasive Surgery, Italy, ²Ospedale S. Camillo-Forlanini Spallanzani, Dipartimento Di Chirurgia Generale E Trapianti, Italy, ³S. Eugenio Hospital, Department of General Surgery, Italy, ⁴Hospital “San Paolo”, UOC of General and Minimally Invasive Surgery, Italy

Aims: Currently, the surgery of choice in the case of sigmoid cancer is left hemicolectomy. Sigmoidectomy is an intervention reserved in most of cases for benign pathologies and mainly in cases of diverticulitis. Few studies in the literature report oncological data after sigmoidectomy for adenocarcinoma. Aim of this study is to report long-term outcomes after laparoscopic sigmoidectomy (LS) for sigmoid adenocarcinoma.

Methods: This study is a retrospective analysis of prospectively collected data. From January 2003 to February 2021, 173 patients underwent elective LS for adenocarcinoma. Twenty-four patients with diagnosis of preoperative distant metastases were excluded (13.9%). Follow-up data of the remaining 149 patients were obtained from Unit of Oncology.

Results: Fifty-one out of 149 patients (34.2%) were lost at follow-up, leaving 98 patients with sufficient data for analysis and forming our study population. Conversion to open surgery was required in three patients for adhesions to previous surgery (3%). Mean operative time was 139.9 ± 35.1 min (range 60-300 min). Overall, seven postoperative complications were observed (7.1%). Two patients (2%) with anastomotic leakage underwent Hartmann procedure (Clavien-Dindo grade III-b). Mean number of lymph-nodes harvested on the specimen was 14.2 ± 7.1 (range 5-47). Mean postoperative hospital stay was 8.8 ± 4.5 days (range 5-42). Readmission and 30-day mortality were nil. At median follow-up of 115 months (interquartile range 133.8) two (2%) and 9 patients (9.2%) developed recurrences and metastases, respectively. Twelve patients (12.2%) died during the study period. Of these, six patients (6.1%) with metastases died for tumor disease progression, and other six patients died for causes not related to the tumor. At 5- and 10-years follow-up the overall survival was 90.5 ± 3.4% and 83.8 ± 4.5%, while disease free survival was 87.1 ± 4.1% and 83.5 ± 4.7%, respectively.

Conclusions: LS for adenocarcinoma is a safe and comparable technique to left hemicolectomy both in terms of the number of resected lymph nodes and of oncological results at 10 years. The possibility of sparing the colon to be resected even lowering the splenic flexure can cause a lower rate of anastomotic fistulas. Further studies are needed to confirm these data.

COLORECTAL—Malignant

P060—Initial Experience with Indocyanine Green Fluorescence Imaging During Minimally Invasive Colorectal Cancer Surgery

Vasil Kyosev ¹ , P. G. I. Ivanov¹, V. M. M. Mutafchijski¹, G. K. K. Kotashev¹, K. S. V. Vasilev¹, G. B. G. Grigorov¹, D. K. P. Penchev¹, M. B. G. Gavrilov¹, T. G. P. Pajcheva¹

¹Military Medical Academy, Endoscopic Surgery, Bulgaria

Aims: One of the main causes of anastomotic leak in colorectal surgery is insufficient vascular supply. Fluorescence imaging by means of Indocyanine green (ICG) have been applied to intraoperatively determine the perfusion of the anastomosis. This study evaluate the feasibility and safety of intraoperative assessment of anastomotic perfusion using ICG angiography in patients undergoing left-sided colon or rectal minimally invasive resection with colorectal anastomosis.

Methods: From October 2018 to March 2020 in our Unit one hundred and two consecutive patients with colorectal cancer who underwent totally laparoscopic surgery were enrolled retrospectively and grouped into the ICFI (Indocyanine green fluorescence imaging group, n = 46) and control group (CG, n = 56). Based on the type of surgery, patients of two groups were divided in two categories: Cat A—left Hemicolectomy (ICFI-A, n = 22/CG-A, n = 34); and Cat B—anterior resection of the rectum (ICFI-B, n = 24/CG-B, n = 22). In the ICFI group, indocyanine green (ICG) was injected intravenously, and the bowel perfusion was observed using a fluorescence camera system prior to and after completion of the anastomosis.

Results: The two groups were demographically comparable. The CG-A&B group exhibited a significantly shorter operative time (p = 0.0417) while intraoperative blood loss did not significantly differ among the ICFI&CG groups (p = 0.078). In the IGFI group, average time to perfusion fluorescence was 42 .6 ± 17.0 s after ICG injection, and twelve patients (26.1%) were required to choose a more proximal point of resection due to the lack of adequate fluorescence at the point previously selected, 7 ICFI-A patients (15.2%) and 5 ICFI-B patients (10.9%). Anastomotic leakage (AL) was occurred in 4 CG-B patients (7.1%) and 2 CG-A patients (3.6%). There were no differences in terms of pathological outcomes and postoperative recovery between the groups (p > 0.05).

Conclusions: ICG leads to signifcantly more changes in the resection line in left hemicolectomy minimally invasive operations than anterior resection and reduce the AL incidence. To confrm this data, further studies with wider sample size and with an objective evaluation of the anastomotic perfusion are required.

Keywords: Minimally invasive surgery, Colorectal cancer, Fluorescence imaging, Indocyanine green (ICG), Fluorescence angiography (FA)

COLORECTAL—Malignant

P061—Laparoscopic Versus Robotic Right Hemicolectomy in Patients with right Colon Cancer—A Literature Review

Joseph Galea ¹ , J. Schembri Higgans¹, P. Andrejevic¹

¹Mater Dei Hospital, Surgery, Malta

Introduction: Colorectal cancer is considered one of the most common cancer types worldwide, accounting for approximately 10% of all annually diagnosed cancers and cancer-related deaths. Right-sided colon cancer constitutes approximately 40% of all colorectal cancer.

Aims: The aims of the literature review were to evaluate the intraoperative, postoperative, survival, and histopathological outcomes, together with cost-effectiveness, comparing laparoscopic right hemicolectomies (LRC) and robotic right hemicolectomies (RRC) for right colon cancer.

Objectives: The specific outcomes assessed included intraoperative blood loss, operative duration, conversion to open procedure (CTOP), overall complications, anastomotic leak frequency, surgical wound infections, time to first flatus, time to first oral diet, length of stay (LOS), mortality rates, resected lymph node yield (LNY), resection margins and cost.

Methodology: A literature review was performed to execute the aims above. Each critiqued article was assigned a level of evidence according to the level of evidence by Harbour and Mills (2001) and each outcome was compared to that in other studies so as to establish an overall conclusion. A list of recommendations was produced summarizing comparability or significant difference between robotic and laparoscopic surgery for right hemicolectomy in right colon cancer. A grade of evidence was assigned to the recommendations formulated.

Results: The results of this literature review concluded comparability between LRC and RRC in terms of intraoperative complications, overall postoperative complications, anastomotic leak rates, postoperative haemorrhage occurrence, abdominal abscess formation rates, postoperative ileus occurrence, non-surgical complications prevalence, wound infection rates, incisional hernia development, pain occurrence, unplanned readmission rates, and re-operation rates. In terms of postoperative bowel recovery, LOS, mortality, survival, and histopathological variables, including LNY, findings were also comparable between the two modalities. A RRC was deemed advantageous in terms of intraoperative blood loss and CTOP, however, limitations persist in terms of operative duration and cost.

Conclusion: The main findings were an increased operative duration and costs when undergoing a RRC, with an advantage regarding intraoperative blood loss and CTOP. Other intraoperative, postoperative, survival, and histopathological variables were comparable.

COLORECTAL—Malignant

P062—Comparison of Proactive and Conventional Treatment of Anastomotic Leakage in Rectal Cancer Surgery; A Multicenter Retrospective Cohort Series

Kevin Talboom ¹ , N. G. Greijdanus¹, N. Brinkman¹, R. D. Blok¹, S. X. Roodbeen¹, C. Y. Ponsioen¹, P. J. Tanis¹, W.A. Bemelman¹, C. Cunningham¹, F.B. de Lacy, R. Hompes¹¹

¹Amsterdam UMC, AMC, Surgery, Spain

Background: Comparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existing. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR.

Methods: This retrospective cohort study included all patients (Feb 2009—Apr 2020) with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pair-wise comparison of conventional treatment and endoscopic vacuum assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at het end of follow-up.

Results: Overall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compare to 78% after EVASC (p = 0.139) and functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs 54%, p = 0.045). Total length of stay was median 30 days after EVASC, compared to 19 days after conventional treatment (p = 0.004). Early initiation of EVASC in the first week after primary surgery, resulted in better functional anastomosis rate compared to late initiation (100% vs 55%, p = 0.008).

Conclusion: Pro-active treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable.

COLORECTAL—Malignant

P063—Oncologic Outcomes of ICG Fluorescence Imaging Guided Laparoscopic Right Hemicolectomy

Jun Watanabe ¹ , Y. Suwa¹, K. Nakagawa², H. Suwa³, M. Ozawa², A. Ishibe², I. Endo²

¹Yokohama City University Medical Center, Department of Surgery, Gastroenterological Center, Japan, ²Yokohama City University Graduate School Medicine., Department of Gastroenterological Surgery, Japan, ³Yokosuka Kyosai Hospital, Department of Surgery, Japan

Aim: To investigate the oncologic outcomes of CME using intraoperative lymphatic flow evaluation by ICG fluorescence imaging (ICG-FI) in laparoscopic right hemicolectomy (LRHC) for right colon cancer.

Methods: From January 2009 to December 2020, 921 patients who underwent D3 dissection for right-sided colon cancer except Stage IV were included. ICG-FI guided LRHC (ICG group) was performed in 233 cases, and LRHC without ICG-FI (non-ICG group) was performed in 688 cases. We compared and examined the oncologic outcomes after Propensity Score matching with age, gender, BMI, ASA-PS, tumor localization, and cStage as covariates.

Results: 231 patients in the ICG group and 231 patients in the non-ICG group were selected. The median operative time was 174 vs 175 min, which was not different (p = 0.737), and the median blood loss was 0 vs 5 ml, which was significantly smaller in the ICG group (p < 0.001). The incidence of complications of Clavien-Dindo classification Grade 2 or higher was 8.2 vs 12.1% (p = 0.109), which was not different. The median number of lymph node dissections is 6 vs 4 (p < 0.001) for the main lymph nodes, 7 vs 6 (p = 0.032) for the intermediate lymph nodes, and 31 vs 27 (p = 0.047) in total, which were significantly more in the ICG group. The 3-year recurrence-free survival by stage is Stage I: 100 vs 100%, Stage II: 87.4 vs 90.5% (p = 0.451), Stage III: 78.2 vs 73.5% (p = 0.709), and the 3-year overall survival is Stage I: 96.8 vs 100% (p = 0.091), Stage II: 92.3 vs 94.3% (p = 0.325), Stage III: 95.8 vs 87.6% (p = 0.364), and there was no significant difference between the two groups. The recurrence type (liver/lung/peritoneal dissemination/lymph node/local/other) was 7/6/2/1/2/1 vs 7/9/7/1/0/1, and there was no difference between the two groups.

Conclusion: Although ICG-FI guided CME may be able to dissect the main and intermediate lymph nodes more precisely, there was no difference in mid-term results or recurrence type.

COLORECTAL—Malignant

P065—Laparoscopic or Robotic Colectomy of Endoscopically Removed Malignant Colorectal Polyps, with One or More High-risk Characteristics

J. Grosek¹, Žan Čebron ¹ , A. Tomažič¹

¹University Medical Centre Ljubljana, Abdominal Surgery, Slovenia

Background and Objectives: Colorectal cancer represents approximately 10% of all diagnosed cancers worldwide as well as in Slovenia. Due to successful screening programs, there is a rise in discovery of precancerous lesions or malignant polyps that can be removed endoscopically with different techniques. There are various factors suggesting additional surgical resection.

Patients and Methods: A retrospective observational study was performed analyzing patients treated in University Medical Centre Ljubljana at the Department of abdominal surgery between January 2017 and December 2020. The study reviews patients with diagnosed and endoscopically removed malignant polyps in which additional surgery resection was performed. We included 75 patients.

Results: More than 80% of resections were performed laparoscopically from 2017 to 2019. In 2020 we began with robotic resections which represented more than a third of all resections in the ongoing year. In 60 patients altogether (80,0%) there were no residual tumor or positive lymph nodes. All the performed resections were radical (R0). We noted some complication in 7 patients, altogether 11 complications were observed.

Discussion: Due to our observation the surgical resection was inevitably required in 20% of patients with the purpose to not negatively impact their oncological outcome.

Conclusions: The incidence of endoscopically removed malignant colorectal polyps is rising due to successful screening programs. Despite known risk factors the question remains, which patients should be offered additional surgical resection to assure the best oncological outcome.

COLORECTAL—Stoma

P066—Stenting for STOMA stenosis in an UNFIT PATIENT: A NOVEL Endoscopic Technique for Unsolved Challenge

Ashutosh Gumber ¹ , K. Shalli¹, M. Patterson¹, A. McLeary¹

¹University Hospital Wishaw, Colorectal, United Kingdom

Introduction: Stoma stenosis is an uncommon but challenging complication faced by the surgeon and patient. Lack of blood supply, obesity, emergency surgery and challenges in maturing the stoma leads to stoma stenosis in up to 9% of the patients. Chances of stenosis with colostomy have been reported higher than ileostomy in the medical literature. Due to rarity of this complication, there is paucity in the literature and a lack of evidence for appropriate management. Often, it mandates an early or delayed surgery for refashioning the stoma, which can be difficult in unfit patients. The aim of reporting this case is to present a newer endoscopic technique of stenting the stenosed stoma as another option for treatment.

Methods: A 61-year-old hypertensive and diabetic gentleman with a BMI of 52 underwent difficult laparoscopic abdominoperineal excision of low rectal tumour following neoadjuvant therapy. The creation of stoma was challenging due to bulky colon and it’s mesertery and the abdominal wall thickness of 118 mm at the pre-marked site in the left abdomen. As per the standard approach, end colostomy was spouted by 1 cm above the skin. Patient developed stoma necrosis in the immediate post-operative period and subsequently severe stenosis. Re-operation was not possible due to body habitus and co-morbidities. A local revision with multiple radial incisions (Fig. 1) followed by insertion of uncovered self expanding Biodegradable (BD) stent (Fig. 2) next day achieved reasonable dilatation. The stent had a diameter of 31 mm and length of 60 mm. Top end of the stent was kept at the level of the mucocutaneous junction.

Results: Challenging major re-operation avoided following a successful novel stenting approach. The stent dissolved in 3 months. Patient continued with dilators subsequently and has a stomal opening of 2.5 cm, fifteen months following the surgery. Further intentional weight loss by 15 kg over the last six months has helped.

Conclusion: Stoma stenosis is a rare condition, and the treatment is often demanding. As an additional tool to deal with such complication, BD stenting proved to be rewarding. It has been therapeutic in this case, but it can certainly allow time for a planned revision or closure of the stoma later.

COLORECTAL—Stoma

P067—Increasing Stoma Requirements During the COVID-19 Pandemic

Naren Kumaran ¹ , V. Vijayaregu², B. Abdelqader³, W.Y. Chang³, R. Polson³, S. Sangal³

¹Northampton General Hospital NHS Foundation Trust, Department of General Surgery, United Kingdom, ²University Hospitals of Leicester NHS Trust, Department of Acute Medicine, United Kingdom, ³University Hospitals of Leicester NHS Trust, Department of Colorectal Surgery, United Kingdom

Aims: The COVID-19 pandemic has led to a change in working practices in the diagnosis and management of colorectal cancer. Surveillance was paused, referral pathways decelerated and waiting times for cancer operations were prolonged. Guidelines emerged which recommended changing anastomotic practice in favour of forming a defunctioning stoma or end stoma in patients who would have previously only had an anastomosis. This study aimed to identify whether changes made during the pandemic have resulted in an increase in patients requiring a stoma and its potential impact.

Methods: All patients diagnosed with colorectal cancer and entered in the authors’ tertiary surgical unit cancer database in three 4-month intervals were included. These corresponded to before the pandemic (March–June 2019), during the UK’s first wave of COVID-19 (March–June 2020), and during the second wave (December 2020–March 2021). The total number of patients diagnosed with colorectal cancer and for those undergoing elective and emergency primary surgical resection, the incidence of stomas was compared between groups.

Results: The total number of patients diagnosed showed a fall from the pre-pandemic number of 147 to 132 in the first wave. This recovered to 152 by the second wave. There was an increase in the interval between referral and surgery during the first wave compared with before the pandemic (average 118 and 78 days respectively; P = 0.003).This was also evident during the second wave. (P = 0.047). For patients undergoing elective surgery the incidence of stomas was 13% before the pandemic. However, this tripled to 39% during the first wave and further increased to 54% in the second wave. Similar trends were seen in patients undergoing emergency surgery with 36% having stomas before the pandemic which rose to 50% during both the waves.

Conclusion: A change in stoma practice was observed with patients having a stoma when they would usually have had an anastomosis only. As COVID-19 continues to have a severe effect on planned surgery in the UK, patients requiring stoma reversal adds to the backlog. As the huge task of clearing the backlog begins, surgical teams must be provided with appropriate resources, professional and mental health support.

COLORECTAL—Stoma

P068—Prophylactic NPWT at Ileostomy Closure in Patients After Colorectal Cancer Operation Reduce Complete Wound Healing Time—Prospective Clinical Trial

Mateusz Wierdak ¹ , M. Pisarska Adamczyk¹, W. Kula¹, B. Roś¹, M. Mizera¹, M. Nowakowski¹, P. Major¹, M. Pędziwiatr¹

¹Jagiellonian University Medical College, 2nd Department of General Surgery, Poland

Aims: We performed a prospective control trial to assess the usefulness of postoperative NPWT in the reduction of postoperative wound healing complications,complete wound healing time and surgical site infections after diverting ileostomy closure, in the group of patients previously operated for colorectal resection due to cancer.

Methods: Prospective study between January 2016 and December 2021 was conducted. Patients with a past history of laparoscopic colorectal surgery due to cancer with protective loop ileostomy scheduled to undergo ileostomy closure with primary wound closure were randomly divided into groups with or without NPWT. Pourse string technique was used in control group. The primary endpoint was the incidence of wound-related complications (WRC) (wound healing complications witch required surgical intervention other than suture removal or dressing changing), and and length of complete wound healing (CWH). The secondary endpoints were incidences of Surgical Site Infection (SSI),the length of postoperative hospital stay (LOS) and assessment of the cosmetic effect of the postoperative scar (by visual analog scale (VAS) and patients satisfaction questionare) 1 and 6 months after surgery.

Results: A total of 35 patients with primary wound closure with Purse String Technique (PST)) and 40 patients with primary wound closure by single skin sutures + NPWT (NPWT group) were enrolled.There were no diferences in WRC ( 6 patients in the PST group, and 4 patient in the NPWT group (p = 0.43) and SSI incidence (4 in SPT group and 3 in SSS + NPWT group) (p = 0.83). Median CWH was significantly shorter in NPWT group [21 (14-28) days in PST group; 7 (7-7)days in NPWT group; p = 0.0302]. There was no difference in LOS between the two groups [median LOS: PST group—4 (2,5-5) days; NPWT group 4 (2-4) days; p = 0,39].We observed siggnificantly better cosmetic short term ( 1 month) outcome in NPWT group in VAS scale [ 6,3 (5,3-7,3) days in PST group; 8,4 (7,9-9,0)days in NPWT group; p = 0.043] without difference in long term (6 months) cosmetic outcome.

Conclusion: Prophylactic postoperative NPWT compared to PST after diverting ileostomy closure in colorectal cancer patients reduces CWH and gives better cosmetic outcome in short term observation, without differences in WMC, SSI incidance and LOS.

COLORECTAL—Stoma

P069—Laparoscopic Exploration and Diverting Stoma of Iatrogenic Colonoscopic Complete Transection of the Sigmoid Colon; A Case Report

Alnazeer Abdelbagi ¹ , N. Abubaker¹, N. Hilal², M. Yousif³, I.A.B. Mohammed¹, O. Mohammed¹, M. Hassan¹, N. Abdalla⁴, M. Mohamed⁵, M. A. Adam⁵

¹University of Khartoum, Department of Anatomy, Sudan, ²Ibn Sina specialized hospital, GIT surgery, Sudan, ³Hamad Medical Corporation, Colorectal Surgery, Sudan, ⁴University of Khartoum, Department of Surgery, Sudan, ⁵University of Khartoum, Soba Center for Audits and Researches, Sudan

Background: Iatrogenic colon perforation (ICP) is one of the complications associated with colonoscopy which can lead to fatal outcomes such as peritonitis and sepsis. The lack of literature regarding complete transection of colon renders this case report of great value.

Case presentation: A 75 years old lady, underwent elective colonoscopy for diagnostic purposes. During the procedure, her condition deteriorated and she developed abdominal pain and destination. Erect CXR showed air under the diaphragm suggestive of perforated viscus (Fig. 1). Therefore, laparoscopic exploration was carried out, massive pneumoperitoneum with purulent peritonitis was found, and the sigmoid colon was found completely transected (Fig. 2). The two loops were exteriorized as a stoma, and a pelvic drain was inserted. The patient was discharged on day 16 postoperatively, in a good condition. The stoma was reversed 8 weeks postoperatively with no further complications.

Discussion: The reported cases of Iatrogenic Colonic Perforation (ICP) associated with colonoscopy are usually limited to a small sized perforation. Here, we are reporting the first case _according to our knowledge_ of iatrogenic complete transection of the colon. Furthermore, the case was managed successfully via laparoscopic approach.

Conclusion: Complete transection of the colon could be considered as one of the iatrogenic complications associated with colonoscopy. Moreover, the laparoscopic approach showed optimal outcomes.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P070—The Optimal Timing of Laparoscopic Cholecystectomy Following Percutaneous Cholecystostomy in Acute Cholecystitis

Kirolos Abdelsaid¹

¹United Kingdom

Introduction: Percutaneous cholecystostomy (PC) is an effective option for high risk and/or delayed presented Acute cholecystitis (AC). However, the optimal timing for subsequent laparoscopic cholecystectomy (LC) as a definitive treatment remains controversial.

Methods: This study includes 41 patients underwent LC following PC for severe AC. We compared the length of tube insertion, period from PC till LC and period from PC removal till LC against co-morbidities, another attack of AC, subsequent pancreatitis/jaundice and operative difficulties in terms of intraoperative adhesions, drain insertion, conversion to open, length of operation.

Results: The median time of length of tube insertion was 36 days (range 5-208) while the median time of PC insertion till LC was 144 days (range 31-744) and for period from PC removal till LC was 78 days (range 0-714). Patients with prolonged tube insertion (more than a month) showed higher risk of developing subsequent pancreatitis and or jaundice (P = 0.04) while intraoperative adhesions was associated with prolonged time from tube insertion till operation (more than 4 months). There was no significant association between neither the length of tube insertion, period from PC insertion till LC nor period from PC removal till LC and other studied parameters.

Conclusion: prolonged time of PC insertion and/or prolonged time form PC insertion till LC in patients with AC have higher risk of pancreatitis and surgical difficulties. Further studies including larger number of patients’ sample is warranted to confirm the outcomes and determine the optimal time of LC following PC in those patients.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P071—Percutaneous Cholecystostomy for Acute Calculous Cholecystitis an Observational Study from a Single Institute

Kirolos Abdelsaid ¹

¹Maidstone & Tunbridge Wells NHS Trust, United Kingdom

Introduction: Although percutaneous cholecystostomy (PC) is generally accepted as a bridge to definitive therapy for acute cholecystitis (AC), which remains cholecystectomy, some patients did not undergo cholecystectomy mostly due to contraindications to surgery. Here, we aimed to audit our clinical practice from a single institute.

Methods: 153 patients presented with AC and initially managed with PC were included. The proportion of patients who did not undergo subsequent LC and their characteristics were analysed.

Results: 27% (41/153) of the study cohort underwent LC while the remaining patients (n = 112) did not receive any surgical intervention.22/122(20%) were presented with AC and coexisting hepatobiliary malignancy. The mean age of the remaining patients (n = 90) was 75 13 years and the median length of drain insertion of those patients 40 days. The majority (57%) was presented with sever AC while 8% had AC with adjacent liver abscess. 55% of those patients did not develop any further attacks of AC after PC removal while 25% deemed unfit for surgery. The rest of the patients (20%) either refused the operation or died before LC. The American Society of Anaesthesiologists (ASA) score was IV in 9% of patients (8/90). 15% (13/90) experienced post PC complications including either blocked stent, pain and cellulitis around tube. The 60-day mortality rate of patients who did not underwent LC was 11% (10/90).

Conclusion: The majority of AC patients treated initially with PC did not undergo subsequent LC. PC in high surgical risk patients with AC could be consider as definitive treatment.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P072—Zooming Inside Narrow Funnel (ZINF) Technique Reduces the Need for Subtotal Cholecystectomy, and Enables Intra operative Cholangiography

Rebecca Swan ¹ , S. Zino¹

¹Ninewells Hospital and Medical School, General Surgery, United Kingdom

Subtotal cholecystectomy (SC) has been advocated for difficult gallbladder to avoid hazardous dissection and biliary injury. Reduced exposure of trainees to open total cholecystectomy, inflamed, and fibrotic hepatocystic triangle might contribute to the growing tendency to perform subtotal cholecystectomy as a bail out procedure. Subtotal cholecystectomy has significant post-operative morbidity and high incidence of recurrent symptoms. This abstract aims to describe a novel technique to dissect difficult oedematous hepatocystic triangle in a safe plane keeping the vital structure safe.

Materials and Methods: A prospectively collected data for laparoscopic cholecystectomy performed by single surgeon between 1st of July 2020 and 31 dec 2021 were evaluated. Zooming Inside Narrow Funnel (ZINF) technique; starts with circular marking of the peritoneum 1-3 cm high on Hartmann’s pouch. The marking is deepened until reaching and preserving the gallbladder mucosa. Then, the dissection is carried out in the submucosal plane toward the Gallbladder neck, zooming inside the narrow funnel made by the wall of the gallbladder except the mucosa. The dissection is mainly performed using blunt and hydro-dissection and progress until the neck of the gallbladder/cystic duct is identified. Once cystic duct is identified intra operative cholangiography could be performed. Dissection in this plane will prevent damage to important structure as the dissection is carried inside the wall of the gallbladder, not inside the GB. Thus, every structure encountered in this plane is sacrifiable by anatomy as it should be related to the gallbladder. Adherent to this technique will protect all the important structure as they are on the other side of the wall of this funnel. Diathermy should not be used for dissection to avoid collateral thermal damage thought the wall of the GB

Results: 171 laparoscopic cholecystectomies were performed during the study period. ZINF approach was necessary in 8 cases (4.6), 4 patients were males. Nassar difficulty grading was IV in 7 cases and III in one case. By using ZINF technique, not only totally cholecystectomy was possible in all cases but also intra operative cholangiography were achieved in 100%. No intra operative or post-operative complication or readmission were recorded. subtotal cholecystectomy was not performed in any of the 171 patients.

Conclusions: Zooming inside narrow funnel (ZINF) technique, is a novel technique that was necessary to avoid subtotal cholecystectomy in 4.6% of cases. This number is very close to the current recorded rate of subtotal cholecystectomy in major centres. ZINF approach also enabled intra operative cholangiography, preventing missing bile duct stones.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P073—Laparoscopic Cholecystectomy and Trans-Cystic Lithotripsy Enable Complete Clearance of Large Bile Duct stones Using SpyGlass™ Discover with Lithotripsy

Rebecca Swan ¹ , T. Tarek¹, R. Shaalan¹, M. Elsallabi¹, C. Kulli¹, I. Tait¹, P. Patil¹, S. Zino¹

¹NineWells Hospital & Medical School, General Surgery, United Kingdom

Aims: Laparoscopic cholecystectomy and bile duct exploration remain the gold standard treatment for gallstone disease that is associated with bile duct stone. Two sessions management with ERCP then laparoscopic cholecystectomy, subject patients to preventable risk of perforation, bleeding, and pancreatitis, especially if patient is fit and keen for cholecystectomy. Trans-Cystic bile duct exploration (TC BDE) appears to have less morbidity than Trans- Ductal BDE (TD BDE). However large BD stones remains the main challenges for Trans-Cystic approach along with inappropriate anatomy. We aim in this abstract to present a complex case of 48y old female with gall stones and large BD stones.

Results: We present a case of 48 year old female with symptomatic gallstone and bile duct stones disease. Patient had previous open right nephrectomy that was complicated with abdominal abscess 17 years ago. Patient had failed ERCP despite Needle-knife papillotomy due to Large mobile and hard papilla. Unfortunately, patient had post ECRP pancreatitis that was complicated with abdominal collection around the head of the pancreases. Collection required radiologically drainage through the anterior abdominal wall, 13 days post pancreatitis. Patient recovered well and consulted for laparoscopic cholecystectomy and BD exploration with high risk of conversion to open. Procedure was planned 6 weeks after discharge. Laparoscopic cholecystectomy was difficult due to adhesions and shrunken gallbladder (Nassar grade IV). Trans-Cystic BDE was performed using basket inside catheter (BIC) technique. SpyGlass™ Discover choledochoscopy showed clear distal CBD and large 12 mm stone in the common hepatic duct. Stone was also very hard and needed high setting of lithotripsy(30, Max). Stone was fragmented successfully and all fragments were extracted using baskets. Cystic duct was suture closed using 3.0 vicryl and two Robinson abdominal drains were left in the abdomen; one in Morrison’s pouch and one in the sub-diaphragmatic space. Patient has uncomplicated post-operative recovery and was discharged home after 5 days. 8 months follow up satisfactory.

Conclusion: Trans-Cystic BD exploration has become safe and feasible even for large bile duct stone with the new technology. ERCP should be avoided in young fit patient especially females as they carry higher risk of post ERCP pancreatitis

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P074—Laparoscopic Cholecystectomy-Related Bile Duct Injuries-Surgical Strategy and Results

Vyara Draganova ¹ , P. l. Chernopolsky¹, V. Bozhkov¹, R. Madjov¹

¹UMHAT " St. Marina"—Varna, Second Surgery Clinic, Bulgaria

Aims: Iatrogenic lesions (IL) of the bile ducts are one of the rare but most unpleasant complications after laparoscopic cholecystectomy. They represent a significant clinical problem that requires serious medical, social and financial resources. Diagnosis, treatment methods, operative risk and outcome of biliary tract injuries vary considerably and are highly dependent on the type of injury and its location.

Methods: For the period 2001-2021 in our Department 69 patients with evidence of iatrogenic lesions of the extra hepatic bile ducts were hospitalized aged 27 to 77 years old. Five of these patients were admitted after primary reconstructive surgery of the biliary tree after laparoscopic cholecystectomy underwent in another hospital, in 4 cases this was the site of the lesion (found intra operatively in two and in the early postoperative period in two others).

Results: In the presence of a partial defect of the extra hepatic bile ducts, in our opinion the most appropriate method of choice is primary reconstruction over Kehr drainage, although the method hides possible occurrence of late biliary strictures. In our series all patients with other types of injuries underwent Roux-en-Y biliodigestive reconstruction –mostly hepatico-jejuno anastomosis and choledocho-jejuno anastomosis. Only in two patients, after careful dissection and preparation of the common bile duct, there was no tension and choledocho-duodeno anastomosis was performed.

Conclusion: The best tactic to prevent iatrogenic lesions of the extra hepatic bile ducts is prevention through good surgical technique. In case of a lesion found during the operative intervention, the best approach and consequently the best results are obtained if the reconstructive operation is performed immediately by an experienced biliary surgeon. When the bile duct injury is diagnosed postoperatively various surgical and endoscopic procedures can be used.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P075—Aberrant Hepatovesical Bile Ducts (Luschka), Identified During Laparoscopic Cholecystectomy. Presentation of 10 Cases

Spyridon Koulas ¹ , G. Athanasiou¹, E. Stefou¹, M. Billis¹, N. Zikos¹, E. Mila¹

¹General Hospital of Ioannina, Department of Surgery, Greece

Background: Anatomic abnormalities of the biliary tree still present challenges during laparoscopic cholecystectomy and affect perioperative and mainly postoperative outcomes. We report a successful outcome of 10 consecutive patients whom presented with an aberrant biliary duct (Luschka duct).

Aim: The aim of this study is the need for investigation of the anatomic variations, not only in the Calot’s triangle but also in the gallbladder fosa in order to achieve an effective and safe guidance for laparoscopic surgeons.

Method: One thousand eight hundred patients, treated with laparoscopic cholecystectomy from January 2013 to December 2018, were studied retrospectively. Laparoscope of 30 degrees (WOLF, Germany) was applied to all cases. A standard technique of Redding and Olsen was performed in all cases. Anatomic structures of cystic duct and cystic artery and conditions of Calot’s triangle, were also recorded.

Results: Laparoscopy has revealed that there are many anatomic variation of cystic artery and cystic duct that occur frequently. Based on our experience, we present ten consecutive cases out of 1.800 laparoscopic cholecystectomies (1,8%) in whom was revealed an abnormal biliary duct, except the cystic duct. All of them were found in the gallbladder fosa originated from the hepatic parenchyma. All ducts were clipped and divided. No leakage was observed to any patient. All patients were discharged the first postoperative day with no complications.

Conclusion: We encountered a rare but clinically significant case of aberrant biliary ducts found during laparoscopic cholecystectomy. That suggests precise understanding of the anatomy of Calot’s triangle but mainly the knowledge of the aberrant biliary ducts in the hepatic fosa, can lead to a safe cholecystectomy. Preoperative MRCP may have a diagnostic value.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P076—Aberrant Right Hepatic Artery Directly Deriving from the Biforcation of Commune and Cystic Artery. An Extremely Rare Anatomical Variation

Spyridon Koulas ¹ , G. Athanasiou¹, N. Zikos¹, G. Papiggioti¹, E. Stefou¹, M. Billis¹

¹General Hospital of Ioannina, Department of Surgery, Greece

A 71-year-old man was admitted to our department in order to undergo an elective laparoscopic cholecystectomy. During the dissection of Callot’s triangle we recognize the cystic duct and cystic artery relatively with ease. Immediately after the right hepatic artery we observed a bifurcation of another artery, originated directly from the cystic trunk. The suvramentioned artery was preserved for 7-8 cm length approximately, until its entrance to the hepatic parenchyma. No other vascular or biliary abnormalities were occurred. Then, cystic duct and cystic artery clipped and divided. The patient recovered without any complications. CT imaging findings which followed the first postoperative day confirmed our assumption. To our knowledge, this is the first case where an aberrant right hepatic artery originates directly after the bifurcation of right hepatic artery and cystic artery.

Conclusions: Given the large number of laparoscopic cholecystectomies performed annually, better knowledge of anatomic variation of cystic artery may prevent arterial and potentially bile duct injury, particularly for those patients with unusual anatomy of the Callot’s triangle.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P077—Long-Term Follow Up of Non-operative Management in Acute Cholecystitis

Christopher Leiberman ¹ , G. Kizis¹

¹Queen Elizabeth University Hospital, Glasgow, Surgery, United Kingdom

Aim: To observe the long-term impact of conservative management on patients admitted with acute cholecystitis.

Background: Surgery is currently the recommended treatment for acute cholecystitis and the WSES recommend that emergency laparoscopic cholecystectomy be performed as soon as possible. However, given the impact of the COVID-19 pandemic on healthcare delivery, this is not always possible. So, what happens to those who are managed conservatively?

Methods: Twenty-eight patients were admitted with acute cholecystitis to a large tertiary hospital in November 2020; twenty-three were discharged without having had a cholecystectomy. These patients were followed up for one year and observed for the development of any gallstone-related admissions and surgical procedures.

Results: Of the 23 patients observed, 30% (n = 7) were admitted for gallstone-related complications. Biliary colic was responsible for 43% of these admissions with pancreatitis (14%), cholangitis (14%), choledocholithiasis (14%), and cholecystitis (14%) causing the rest. Only 9% (n = 2) received a laparoscopic cholecystectomy. In both cases it was in an emergency setting during an admission for biliary colic.

Conclusion: Long-term observation of conservatively managed acute cholecystitis was possible in around two-thirds of patients as no gallstone-related hospital admissions were observed. Biliary colic was the most common cause gallstone-related admissions. Longer observation is required to assess the feasibility of long-term non-operative management in acute cholecystitis.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P078—Laparoscopic Cholecystectomy in Complet Situs Inversus—Take a Good Look in the Mirror

Elena Adelina Toma ¹ , O. Enciu¹, A. Miron¹

¹Elias Emergency Univeristy Hospital, General Surgery, Romania

Laparoscopic cholecystectomy has been the standard of surgical care for symptomatic gallstones for more than two decades, but the learning curve for this highly standardized procedure is still difficult to significantly reduce the risk of injury to noble structures in the Calot triangle.

Surgery in patients with situs inversus totalis is a technical challenge and although many authors recommend that it be performed by an experienced surgeon, the operation can be a success for any operator if the approach is carefully studied preoperatively. Preoperative imaging (tomography or magnetic resonance imaging) is considered useful to assess any vascular or bile duct abnormalities that may increase the risk of intraoperative injury.

The most important element, however, remains the location of the work trocars, the positioning of the surgeon and the assistant, in order to attain critical view of safety and the safe conclusion of the intervention. Several surgical options have been proposed that improve operative ergonomics: surgeon and trocars positioned "in the mirror" compared to the classic position, surgeon and patient in French position, with trocars positioned in a classic or modified location, optical trocar in subumbilical position, or single-port surgery where possible. The challenge is to make maximum use of the surgeon's dexterity for a routine and highly standardized but mirrored operation. Following the analysis of several studies in the literature and extensive preoperative planning, we present the technique used in our clinic for a 38-year-old patient with situs inversus totalis and calculous cholecystitis.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P079—A Rare Intrahepatic Haematoma Following Laparoscopic Cholecystectomy and Intraoperative Endoscopic Retrograde Cholangiopancreatography—Case Report

Mark Medic ¹

¹UKC Ljubljana, Abdominal Surgery, Slovenia

Intrahepatic haematoma following either laparoscopic cholecystectomy or endoscopic retrograde cholangiopancreatography is a rare complication. We present a case of a 49-year-old female with a large 18 × 15x6 cm intrahepatic haematoma in the right lobe, following a laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography.

Intrahepatic haematoma is a known complication in both procedures, with different possible pathophysiological cause.

As far as we know, this is the first described case of intrahepatic haematoma following laparoscopic cholecystectomy, with intraoperative endoscopic retrograde cholangiopancreatography. We discuss the causes and possible treatment.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P080—Management of Nom Failure in Iatrogenic Bile Duct Injury After Laparoscopic Cholecystectomy and Ercp Stenting

Emanuele Doria ¹, S. Carini³, I. D’Addea³, E. Doria³, R.M. Lauro³, F. Masci³, G.S. Necchi³, E. Pastore³, V. Raveglia³, A. Scorza³, P.G. Traini³, M. Paganelli², F. Cipriani², L. Aldrighetti²

¹Luini confalonieri, General Surgery Unit, ASST Settelaghi, L. Confalonieri Hospital, University of Insubria, Luino, Varese, Italy, ²Hepato-Biliary Surgery Unit, University “Vita e Salute” San Raffaele Hospital, Milan, Italy, ³General Surgery Unit, ASST Settelaghi, L. Confalonieri Hospital, University of Insubria, Luino, Varese

Background: In the event of Minor Bile Duct Injuries (BDI) detected during laparoscopic Cholecystectomy, surgeons must promptly analyse the injury and choose between an intraoperative repair or "drain now and fix later" strategy. In case of failure of NOM for worsening of symptoms of the patient may be indicated an ERCP with sphincterotomy ± stent placement.

Case Report: A 54-year-old male patient with severe acute-chronic cholecystitis came to our attention. An emergency laparoscopic cholecystectomy was carried out. The gallbladder pouch was attached to the CBD. A minimal bile leak was detected over the dissection of the Calot Triangle (Gost Calot). After the Cholecystectomy, the gallbladder bed was drained with an 18F drain. Given the increase of drainage output, we chose non-operative management (NOM) since a Cholangio-MRI showed a suspected minimal biliary leakage from the CBD. According to Strasberg's classification, the bile leak and injury of the CBD were supposed to be Type D. Since the bile output from the drain was still consistent, the patient underwent two attempts of ERCP, with unsuccessful cannulation of the CBD. Two days later, a biliary stent was inserted through ERCP in another institution in Milan with high-volume ERCP. After the procedure, the patient's general condition worsened for a progressive increase of drainage output associated with fever. The CT abdominal scan showed a suspected stent dislocation through the right bile duct injury. The patient was moved to a High-volume Hepatobiliary Surgery Unit in Milan. A diagnostic laparoscopy was carried out, and the stent dislocation along with Strasberg's Type E4 injury instead was detected. The stent was removed, and two "Bracci" biliary catheters were inserted in the right and left hepatic duct. Multiple drains were positioned. Eighteen days later, the CBD was reconstructed with 4B liver segment resection end an end-to-side anastomosis of the biliary sheath and jejunostomy tailoring according to Delaney's procedure.

The post-operative course had no severe surgical complications. The patient was discharged on day 14th.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P081—Gallbladder Torsion- A Case Report and Review of Literature

Naren Kumaran ¹, I.G. Shiekh²

¹Northampton General Hospital NHS Foundation Trust, Department of General Surgery, United Kingdom, ²Kettering General Hospital NHS Foundation Trust, Department of General Surgery, United Kingdom

Background: Torsion of the gallbladder is a rare surgical entity. The clinical presentation mimics acute cholecystitis in most cases. There are no clear clinical signs for diagnosis and it has been reported that preoperative diagnosis is difficult.

Method: A 79 year old female patient presented with a six day history of right sided abdominal pain associated with nausea and reduced appetite. The patient was hypotensive, tachycardic and pyrexic. The white cell counts were 28.5, C-reactive protein was 270 and the eGFR was 14.5. The patient was resuscitated with intravenous antibiotics and fluids.

Results: The patient had a CT abdomen which reported a large right flank fluid collection of unknown aetiology and possibilities include abscess related to biliary disease, peptic disease and colonic disease. The patient was taken for a laparotomy where the diagnosis of a torsion gallbladder was made intraoperatively. A cholecystectomy was performed. The postoperative period was uneventful.

Conclusion: First reported by Wendel in 1898, gallbladder torsion is an uncommon surgical emergency. Predisposing factors are considered to be female sex and old age. The anatomical variation which predisposes the gallbladder for torsion is a long mesentery instead of a wider attachment to the liver. In some cases the mesentery might be absent altogether. Marano et al., in their report described the various anatomical variations seen in cases of gallbladder torsion. The first one is what they called a “free-floating gallbladder” suspended only by the mesentery of the cystic duct. The second type, is where the gallbladder has a long freely mobile mesentery where torsion occurs around the gallbladder or mesenteric axis. A recent metanalysis suggests that within the last twenty years a quarter of patients get diagnosed preoperatively.

The treatment of a gallbladder torsion is cholecystectomy. As expected, it is more than often, an open cholecystectomy, due to a diagnostic dilemma at presentation. However if a preoperative diagnosis is made a laparoscopic approach can be adopted as well. To conclude gallbladder torsion continues to be a rare diagnosis and can have varying presentations. Early intervention with a cholecystectomy continues to be the definitive treatment.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P082—Safety Evaluation of Minilaparoscopic Cholecystectomy

Mykola Mendel ¹, Y.V. Pavlovych²

¹PI “Dobrobut Academy”, Surgery, Ukraine, ²Shupyk National Medical Academy of Postgraduate Education, Surgery, Ukraine

Aims: The aim of the study was to evaluate safety of minilaparoscopic cholecystectomy (MLC) on the basis of critical view of safety (CVS) achievement.

Methods: The analysis of 45 video recordings of sequential operations MLC performed in 2015-2020 was carried out. The operations were performed using instruments 3 mm in diameter. The analysis was carried out independently by two co-authors; if the assessments did not coincide, a joint revision of the records was carried out. Indications for the operations were symptomatic cholelithiasis—41 patient, choledocholithiasis (after ERCP)—1 patient, and gallbladder polyps larger then 10 mm—3 patients. All patients were operated on by one surgeon. There were evaluated achievement of CVS (anterior and posterior view) by D. Sanford (2014), presence of anatomical variations and difficulty of laparoscopic cholecystectomy grade by A. Nassar (2015).

Results: There were 45 patients—44 females and 1 male who requested MLC due to cosmetic reason. Mean age was 38,5 years (from 23 to 54), body mass index was from 19 to 29 kg/sq.m. Operation length was 59,4 min (from 35 to 90). Difficulty of laparoscopic cholecystectomy grade by Nassar was: 1 grade—39 patients and 2 grade—6 patients. Typical anatomy was noted in 31 patients, and anatomical variations were noted in 14 (31,1%) patients (multiple small arteries without a clear arterial trunk—4, two cystic arteries—4, Caterpillar (Moynihan’s) hump of right hepatic artery—3, anterior cystic artery—2, cystic artery from gastroduodenal artery—1). CVS was completely achieved in 41 (91,1%) cases, doesn’t achieved in 4 cases (8,9%) due to the need to transect the cystic artery, which interfered with complete dissection. CVS was then reached before clipping or ligating cystic duct (we defined this type of CVS as “revised”). Anterior CVS according to Sanford achieved in 41 patients (mean score—5,5 of 6 maximal), posterior CVS achieved in 38 (mean score—5,2). The unreached posterior CVS is explained by the fact that at the beginning of the work we did not pay attention to the posterior view when reaching the anterior view. The average score of the foto doublet was 10,7. The average hospital stay was 1,2 days. There were no complications.

Conclusion(s): In MLC the CVS was achieved in 91,1% of cases, in 8,9% of cases CVS was not achieved formally due to transection of the cystic artery before the end of the dissection. MLC does not differ in safety from traditional laparoscopic cholecystectomy for elective surgery of gallstone disease and has good cosmetic results.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P083—Emphysematous Cholecystitis: A Diagnostic Dilemma and Treatment Challenge

Ahmed Elnabil-Mortada ¹, M. Matias¹, R. Ackroyd²

¹Ain Shams University—Faculty of Medicine/Sheffield Teaching Hospitals, General Surgery, Egypt, ²Sheffield Teaching Hospitals, General Surgery, United Kingdom

Background: Emphysematous cholecystitis (EC) is a rare life-threatening variant of acute cholecystitis. It is commonly seen in elderly men who are immunocompromised or have diabetes mellitus, or peripheral vascular disease. It is caused by gas-forming organisms such as Escherichia coli, Clostridium perfringens and Bacteroides fragilis and has a reported mortality of up to 25%. CT is the most sensitive diagnostic imaging study for the detection of intraluminal or intramural gallbladder gas.

Methods: We report a diagnostic dilemma and multidisciplinary management of a case of emphysematous cholecystitis with unusual presentation in a healthy patient with no risk factors.

Results: A 47-year-old male chef presented with a clinical picture of sepsis and abdominal pain. Initial investigations were normal apart from bilateral basal atelectasis, for which he was treated as pneumonia. He did not improve, with persistent fever and further investigations established the diagnosis of emphysematous cholecystitis. His clinical condition improved dramatically after urgent laparoscopic cholecystectomy on day 6. He was discharged on day 12 on completion of a course of IV antibiotics, with an uneventful postoperative recovery.

Conclusion: A high index of clinical suspicion and multidisciplinary team management including surgery, radiology, and microbiology is crucial for early diagnosis of the rare life-threatening condition of emphysematous cholecystitis. EC is not limited to elderly morbid patients. Urgent laparoscopic cholecystectomy is the best treatment where feasible.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P084—Comparative Study of Early Versus Delayed Laparoscopic Cholecystectomy Following Endoscopic Sphincterotomy for Mild to Moderate Acute Biliary Pancreatitis

E. Marks¹, Bhavesh Devkaran ¹ , S. Sharma², S. Sodhi³, A. Chauhan², B. Sharma⁴

¹Royal Liverpool and Broadgreen University NHS Trust, General Surgery, Renal Transplant and Vascular Access, United Kingdom, ²IGMC Shimla, General Surgery, India, ³IGMC, Anaesthesia, India, ⁴IGMC, Gastroenterology, India

Introduction: Acute pancreatitis is an inflammatory disease of the pancreas with acute biliary pancreatitis (ABP) accounting for 75% of cases and elective cholecystectomy has long been recommended for patients with acute gallstone pancreatitis. Current recommendations however favour early laparoscopic cholecystectomy (LC) for mild acute gall stone pancreatitis during the same index admission to prevent recurrent attacks which have been reported to be as high as 18-61% in various studies with 4-50% being severe recurrent attacks. ERCP with endoscopic sphincterotomy (ES) is established as an initial treatment for severe acute gallstone pancreatitis and has been shown to reduce the complication rate, morbidity, and mortality for selected patients but there are no recommendations for mild and moderate cases. Endoscopic sphincterotomy in these cases who are unfit for cholecystectomy during the index admission or there is delay in cholecystectomy due to logistics may benefit from ES while waiting for elective cholecystectomy, in terms of reducing the number of recurrent attacks and decreasing morbidity.

Methods: A total of fifty-seven (57) patients of mild to moderate ABP were included in this study and were divided into three groups. In group A, 19 patients underwent LC within 5 days of admission. In group B, 19 patients underwent ES within 7 days of onset of pain abdomen and had LC within 4 weeks of initial illness. In group C, 19 patients after being managed conservatively initially underwent LC after 8 weeks of attack. These groups were evaluated for level of difficulty of cholecystectomy, recurrent attacks of pancreatitis and associated morbidity.

Results: All patients had mild to moderate pancreatitis with a CT severity score of less than 6. In Group A, all patients underwent laparoscopic cholecystectomy within 10 days of admission. Difficult LC in terms of adhesions, calots anatomy was seen in 17(n = 57) patients. 13(n = 38) patients had recurrent attack of pancreatitis during the waiting period for cholecystectomy, 2(n = 19) in the ER group and 11(n = 19) in the conservative management group, with all patients in the conservative group having more than 2 recurrent attacks. Hospital stay in group A ranged from 1-5 days (2.37 ± 1.11), in group B, from 4-11 days (6.47 ± 2.01) and in group C, from 5-15 days (8.05 ± 2.41) days.

Conclusion: LC in early period is a safe, effective, and feasible in patients of gallstone induced pancreatitis. ES is well tolerated and is a viable alternative to cholecystectomy in high surgical risk patients for the prevention of recurrent pancreatitis till the time of definitive treatment in the form of LC for ABP.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P085—Comparative Study of Single Clip (SCLC), Two Clip (TCLC) and Clipless Cholecystectomy (CLLC) Using Harmonic Ace Versus Conventional Laparoscopic Cholecystectomy (CLC)

Bhavesh Devkaran ¹, A. Attri², U.K. Chandel³, A.K. Kaundal³, K. Sayal⁴

¹Royal Liverpool and Broadgreen University NHS Trust, General Surgery, Renal Transplant and Vascular Access, United Kingdom, ²IGMC Shimla, General Surgery, India, ³IGMC, General Surgery, India, ⁴IGMC, Anaesthesiology, India

Introduction: Gallstones are a common digestive disorder that constitutes a significant health problem. The incidence of cholelithiasis varies greatly and Laparoscopic cholecystectomy has been accepted as the “gold standard” for the treatment of symptomatic gallstone disease. Advanced energy source mainly harmonic scalpel, provide the advantage of shorter operating time by reducing smoke, bloodless dissection in calot’s triangle, lower risk of bleeding from cystic artery due to secure vessel sealing and reducing use of large number of titanium clips. Conventionally 6 titanium clips are used for laparoscopic cholecystectomy, 3 for cystic duct and 3 for cystic artery before division. The cost for using 6 titanium clips are high, therefore by using lesser number of titanium clips we aimed at reducing overall cost as well as time used in laparoscopic cholecystectomy. In addition, various studies have reported that clips have been associated with complications in form of migration.

We compared the advantages of single clip laparoscopic cholecystectomy (SCLC), two clips laparoscopic cholecystectomy (TCLC) and clipless laparoscopic cholecystectomy (CLLC) using single vikryl suture using harmonic ace with conventional laparoscopic cholecystectomy (CLC) using 6 clips and standard electrocautery.

Material and Methods: This study included 200 patients of proven gallstones over a period of 1 year. Patients were randomly divided into four groups with each group consisting of 50 patients. Group 1, included patients undergoing dissection of gall bladder by harmonic scalpel with application of one titanium clip on cystic duct, Group 2 included patients undergoing dissection of gall bladder by harmonic scalpel with application of two titanium clips on cystic duct, Group 3 included patients undergoing dissection of gall bladder by harmonic scalpel with application of absorbable Vikyl suture on cystic duct. In all these groups the cystic artery was divided with harmonic ace without use of clips and the gall bladder was also dissected throughout with the use of the harmonic ace. Group 4 included patients undergoing gall bladder dissection by conventional method of electrocautery and application of 3 clips each on the cystic duct and artery before division. Both intra and post operative were assessed and analysed statistically.

Results: Out of the 200 patients,157 were females and 43 were males. Mean operative time was statistically significant when CLC was compared with SCLC, TCLC and CLLC (CLC 43.10 ± 9.68 min vs 26.80 ± 8.44 in SCLC, 28.76 ± 8.23 IN TCLC, 37.30 ± 8.22 min in CLLC group). Approximate blood loss in the CLC group was 28.90 ± 11.71 ml as compared to 7.8 ± 3.06 in SCLC, 8.10 ± 3.18 ml in TCLC and 8.40 ± 3.70 ml in the CLLC group. Pain score was significantly better in the SCLC, TCLC and CLLC group. 16 patients required drains in the CLC group as compared to 2 in SCLC, 3 in TCLC and 4 in the CLC group. Conversion to open cholecystectomy was comparable in all the groups. Post operative complication in the form of hematoma was significantly more in the CLC group. Overall cost was significantly high in the CLC as compared to the other groups.

Conclusion: SCLC, TCLC and CLLC are comparable to standard 6 clip laparoscopic cholecystectomy in all aspects. SCLC and TCLC have a clear advantage of decreased operative time and blood loss. In addition, all these techniques have a lower cost as compared to conventional laparoscopic cholecystectomy. Further studies involving a large cohort of patients may lead to SCLC, TCLC and CLLC becoming the new standard of laparoscopic cholecystectomy.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P086—Laparoscopic Choleystectomy Plus Intraoperative Cholangiography in a patient with Liver Cirrhosis and Accessory Hepatic Duct

Ángel Javier Lara Valdez ¹ , S. J. Salgado Arzate¹, J. Vargas Flores¹, Y. S. Castillejos Márquez¹, A. Jimenez Leyva¹, I. De Alba Cruz¹, J. A. Dominguez Rodríguez¹, J. A. Martin Perez¹, J. Sánchez Lora¹, A. J. Lara Valdez¹, A. L. Sánchez Baltazar¹, J. Chernitzky Camaño¹, H. F. Narváez González¹, L. Perna Lozada¹, G. Tenorio Arguelles¹, A. J. Tapia Esquivel¹

¹ISSSTE Zaragoza, Surgery, Mexico

Aims: Demonstrate the resolution of a complex case of chronic lithiasic cholecystitis and the importance of intraoperative cholangiography to rule out choledocholithiasis in a patient with liver cirrhosis.

Methods:62-year-old female, history of liver failure secondary to chronic antifungal intake. His condition began with 10 days of evolution with abdominal pain localized in the right upper quadrant, with cholangitis grade II, ultrasound without bile duct dilatation, 3 mm bile duct, 4 mm wall, with data of liver cirrhosis. Laboratories, leukocytes of 15.5. platelets 103 thousand, direct bilirubin 14.2. So it is scheduled for laparoscopic cholecystectomy.

Results: During laparoscopy, a macronodular liver, ascites, multiple adhesions, a thin-walled gallbladder were found, an intraoperative cholangiography was performed, finding a dilated bile duct without evidence of choledocholithiasis, and an accessory duct located at the confluence of the bile duct was observed. Two days after the surgical event, the patient presented digestive tract bleeding for which endoscopy was performed, finding forrest IIA gastric ulcer, sclerotherapy was performed, and hemoclip was also placed, later patient Good evolution, tolerated diet and discharged to the days.

Conclusions: Intraoperative cholangiography is useful in determining choledochal stones. It allows to discover up to 5% of stones in the bile duct not detected preoperatively. And identify bile duct abnormalities.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P087—Cholecysto-Choledochal Fistula Resolved by Laparoscopic Bile Duct Exploration + Choledocoplasty in a Patient with Mirizzi Syndrome Type IV

Hugo Fernando Narváez González ¹ , A. L. Vargas Ávila¹, S. J. Salgado Arzate¹, J. Vargas Flores¹, Y. S. Castillejos Márquez¹, A. Jimenez Leyva¹, J. A. Dominguez Rodríguez¹, I. De Alba Cruz¹, J. Sánchez Lora¹, A. J. Lara Valdez¹, L. Perna Lozada¹, P. R. Pabel Rubén¹, E. M. López Pacheco¹, G. Tenorio Arguelles¹, A. M. Quiroz Silva¹, L. G. Luna León¹

¹ISSSTE Zaragoza, Surgery, Mexico

Aim: Mirizzi Syndrome (MZ) is an uncommon complication of chronic gallstone disease characterized for an extrinsic compression of the bile duct due to indirect pressure applied upon it by an impacted stone in gallbladder, detected from 0.06% to 5.7% of patients during cholecystectomy, and 1.07% undergoing endoscopic retrograde cholangiopancreatography (ERCP). The aim of the study was to show the management of the MZ type IV using a bile duct exploration + choledocoplasty in a patient with cholecysto-choledochal fistula.

Methods: A healthy 46 years old woman with a history of 2 caesarean arrived to the Emergency Department of our hospital reporting 48-h of severe abdominal pain irradiated from the epigastrium to the right upper quadrant. The pain was getting worse, with fever and jaundice, unrelieved by analgesics. Laboratories, ultrasound, and magnetic resonance cholangiopancreatography were performed with a result of an acute cholangitis secondary to choledocholithiasis. Thus, an ERCP and cholangioscopy were done giving the evidence of cholecysto-choledochal fistula that cannot be resolved by an ERCP. Therefore, a surgery was practiced.

Results: The relevant findings were adhesions among duodenum, gallbladder, and omentum. The gallbladder dissection plane was not found. In contrast, the bile duct was identified, consequently, a choledocotomy and biliary duct exploration were attained. Three stones (three centimeters) were found and removed. A revision was carried out with a fogarty catheter without evidence of residues. A Kher probe was placed in the bile duct and a choledocoplasty was made. Finally, on the fifth day the patient was discharged from the hospital.

Conclusions: The surgical management is the mainstay treatment for MZ. Although, the laparoscopic technique is associated with high conversion rates ranged from 11.1% to 80% and an increased incidence of bile duct injury, it possesses many advantages that included shorter hospital stay, reduced wasted of resources, and avoiding bilioenteric bypass reducing morbidity and mortality. Despite experts recommend laparoscopic approach to manage only MZ type I, there are evidences of a successful laparoscopic resolution in other types of MZ using optimal techniques performed by the expertise of specialized surgeons, as well as in the case described here.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P088—Diagnostic Accuracy of Transabdominal Ultrasound for the Detection of Gallbladder Polyps

James Lucocq ¹ , J. Scollay¹, P. Patil¹

¹Ninewells Hospital, Department of General and Upper GI Surgery, United Kingdom

Introduction: Gallbladder cancer is associated with significant morbidity and mortality. Early identification of pre-malignant or low stage tumours improves prognosis. The evidence supporting transabdominal ultrasound (US) in the detection of gallbladder polyps is limited yet it is the main diagnostic imaging modality. The aim of the present study is to investigate the diagnostic accuracy of transabdominal US for true gallbladder polyps.

Method: A cohort of 2768 patients who underwent a laparoscopic cholecystectomy (LC) were included and the pre-operative radiological findings and histopathology results were reported. The rate of true polyps and the utility of USS for the identification of polyps were determined.

Results: Fifty-seven patients (2.1%) had polyps identified on ultrasound pre-operatively (median number, 1; median size, 0.5 cm). Three-point seven percent (2/57) were true polyps, 28.1% (16/57) pseudo-polyps and in 68.4% of cases (39/57) no polyps were found on histopathological analysis. US demonstrated a sensitivity, specificity, PPV and NPV for polyps of 75%, 98.6%, 31.6% and 99.8%, respectively. The true polyps measured 0.9 cm and 1.6 cm and were larger than other polyps on ultrasound (p = 0.03).

Conclusion: Despite current guidance, patients frequently undergo cholecystectomy for small polyps (< 1 cm). In most cases (96.4%) these are not found or were pseudo-polyps on histopathology. USS is a poor modality for the identification of true polyps that may subject the patient to undue anxiety, unnecessary follow-up and cholecystectomy. The utilisation of alternative imaging modalities such as MRI should be investigated further.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P089—Defining Prolonged Length of Stay Following Elective Laparoscopic Cholecystectomy and Validation of a Pre-operative Risk Score

James Lucocq ¹ , J. Scollay¹, P. Patil¹

¹Ninewells Hospital, Department of General and Upper GI Surgery, United Kingdom

Background: Elective Laparoscopic cholecystectomy (ELLC) patients can suffer a prolonged length of stay (PLOS) secondary to several operation-related adverse outcomes. It is well recognised that PLOS following surgical procedures is associated with operation-related morbidity. Acknowledgement of the pre-operative risk factors for PLOS following ELLC will aid the risk-stratification process, the consent process and inform the feasibility of day-surgery.

Method: A cohort of 2166 ELLC were used to determine the relationship between PLOS and operation-related adverse outcomes. The optimal cut-off of PLOS as a predictor for operation-related adverse outcomes was found using receiver operating characteristic (ROC) curves and was defined as the cut off for PLOS. Multivariate logistic regression was conducted on a sub-cohort to derive a pre-operative model to predict PLOS. ROC curves were performed to validate the model. Patients were stratified by the risk tool and the risks of PLOS were determined.

Results: A length of stay of ≥ 3 days following ELLC demonstrated the best diagnostic ability for operation-related adverse outcomes (AUR = 0.96) and was defined as the cut off for PLOS. The rate of PLOS was 6.6% (144/2166) and 100% (144/144) of PLOS patients had an operation-related adverse outcome. PLOS was strongly associated with all operative-related adverse outcomes including subtotal, conversion, intra-operative complications, drains, post-operative complication/imaging and intervention (p < 0.001). The model demonstrated good diagnostic ability for PLOS in the derivation (AUC = 0.81) and validation cohorts (AUC = 0.76) and included the variables of age 40-60, age > 60, ASA 2, ASA ≥ 3, ≥ 3 previous hospital admissions, cholecystitis, pre-operative ERCP and pre-operative cholecystostomy.

Discussion: Prolonged length of stay (≥ 3 days) is an important proxy for operation-related adverse outcomes. Although the rate of PLOS is low following ELLC, morbidity in these patients is significant and pragmatic patient selection in accordance with the risk tool will improve resource utilisation, risk-stratify patients and improve the consent process.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P091—Minimally Invasive Cholecystectomy with Indocyanine Green Fluorescent Cholangiography—Initial Experience

Vasil Kyosev ¹ , P. G. Ivanov¹, V. M. Mutafchijski¹, G. K. Kotashev¹, K. S. Vasilev¹, G. B. Grigorov¹, D. K. Penchev¹, M. B. Gavrilov¹, T.G. Pajcheva¹

¹Military Medical Academy, Endoscopic Surgery, Bulgaria

Aims: Last years in the surgical practice, indocyanine green (ICG) fluorescent cholangiography (FC) has been adopted to perform intra-operative biliary mapping and identify extrahepatic biliary anatomy during minimally invasive cholecystectomy (MIC). This study aimed to emphasise the use of ICG-FC in MIC and compare their results with MIC without use of ICG-FC.

Methods: For period of one year (2019) in our unit were retrospectively reviewed 126 patients which underwent MIC. Pre-operative workup included laboratory blood tests and ultrasonography to assess main biliary tree. The ICG dosage in group with use of ICG-FC was 10 mg injections with time of administration 10-12 h prior to surgery. We evaluated three parameters in both groups: the total operative time (P1), the time of cystic duct disection, clipping and sectioning (P2), and the time of gallbladder release from hepatic fossa (P3). During surgery, imaging data were collected for analysis.

Results: We operated 72 patients using standard technique (MIC) and 54 patients using ICG-FC (MIC + ICG). There were 68 females and 58 males, with median age at surgery of 57.6 years (range 23–81). No conversions were reported in our series. We observe more than 90% visualization of the cystic duct (CD), common bile duct (CBD), CD-CBD junction and the common hepatic duct (CHD) during dissection in MIC + ICG group. Intra-operative complications occurred in 11 MIC patients (15.3%): 5 bleedings from the Calot’s triangle, 2 partial damage to CBD and 4 bleeding from the liver bed during the gallbladder removal. MIC was significantly faster in all parameters (P1, P2, P3) in MIC + ICG group than in MIC group (p = 0.001).

Conclusions: MIC-ICG is safe procedure and based upon our initial experience, we strongly recommend the use of ICG-FC in all patients undergoing MIC. ICG-guided fluorescence provided an excellent real-time visualization of the extrahepatic biliary tree and allowed faster and safer dissection, minimizing the risk of bile duct injuries.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P092—Surgical Outcome of Percutaneous Transhepatic Gallbladder Drainage in Acute Cholecystitis– Ten Years’ Experience at a Tertiary Care Centre

Szabolcs Ábrahám ¹, I. Tóth¹, R. Benkő², M. Matuz², G. Kovács³, Z. Morvay³, A. Nagy³, A. Ottlakán¹, L. Czakó⁴, Z. Szepes⁴, D. Váczi¹, Z. Simonka¹, A. Paszt¹, A. Petri¹, G. Lázár¹

¹University of Szeged, Department of Surgery, Hungary, ²University of Szeged, Department of Clinical Pharmacy, Hungary, ³University of Szeged, Radiology Department, Hungary, ⁴University of Szeged, First Department of Internal Medicine, Hungary

Background: Percutaneous transhepatic gallbladder drainage (PTGBD) plays an important role in the treatment of elderly patients and/or patients in poor health with acute cholecystitis (AC). The primary aim of this study is to determine how these factors influence the clinical outcome of PTGBD. Moreover, we assessed the timing and results of subsequent cholecystectomies.

Patients and Methods: We retrospectively examined the results of 162 patients undergoing PTGBD between 2010 and 2020 (male-female ratio: 51.23% vs. 48.77%; mean age: 71.43 ± 13.22 years). Patient’s performance status, the severity grade of AC and intervention outcomes were assessed with clinical success rates (CSR) and in-hospital mortality. The conversion rate (CR) of possible urgent or delayed, elective laparoscopic cholecystectomies (LC) after PTGBD.

Results: PTGBD was the definitive treatment in 42.18% of patients, while it was a bridging therapy prior to cholecystectomy (CCY) for the other patients. CSR was 87.97%, it was only 64.29% in grade III AC. In 9.87% of the cases, urgent LC was necessary after PTGBD, and its conversion rate was approximately equal to that of elective LC (18.18 vs. 17.46%, respectively, p = 0.2217). Overall, the post-PTGBD in-hospital mortality was 11.72%, while the same figure was 0% for grade I AC, 7.41% for grade II and 40.91% for grade III. Based on logistic regression analyses, in-hospital mortality (OR: 6.07; CI: 1.79–20.56), clinical progression (OR: 7.62; CI: 2.64–22.05) and the need for emergency CCY (OR: 14.75; CI: 3.07–70.81) were mostly determined by AC severity grade.

Conclusion: PTGBD is an easy-to-perform intervention with promising clinical and technical success rates in the treatment of acute cholecystitis. After PTGBD, the level of gallbladder inflammation played a decisive role in the course of AC. In a severe, grade III inflammation, we have to consider low CSR and high mortality.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P094—The Results of Combined Laparoscopic and Choledoscopic Common Bile Duct Stones Extraction with Primary Closure of Common Bile Duct

A Ukhanov ¹ , D. Zakharov¹, S. Bolshakov¹, S. Zhilin¹, A. Leonov¹, K. Muminov¹, J. Aselderov¹

¹Central Municipal Clinical Hospital, Surgical, Russia

Aim: To evaluate the results of primary closure of common bile duct after laparoscopic common bile duct extraction using choledochoscopy.

Materials and Methods: 36 patients undergoing laparoscopic common bile duct exploration in emergency surgical department in the period from 2017 till 2021 years were included in the study. Age of the patient varied from 25 till 78 years. Intraoperative cholangiography and choledochoscopy was carried out during laparoscopic intervention. Preoperative and intraoperative parameters including the technique of CBD closure are presented in the report as well as the discussion of postoperative morbidity, complications, length of hospital stay.

Results: The average duration of combined laparoscopic and choledochoscopic interventions was 98 ± 24.8 min (range, 70 to 210 min). The number of extracted gallstones varied from 1 till 8. Transient bile leakage was seen in 3 patients and in two cases required relaparoscopy and additional choledochotomy suturing. There was no mortality during postoperative period.

Conclusion: Primary closure of common bile duct after of combined laparoscopic and choledoscopic stones extraction is feasible, safe and associated with minimal morbidity. The routine use of this procedure is recommended based on our experience.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P095—Single Incision Laparoscopic Cholecystectomy vs Conventional Laparoscopic Cholecystectomy: A Meta-analysis of the literature

Mark Portelli ¹, S. Attard¹, T. Bezzina², P. Andrejevic¹

¹Mater Dei Hospital, Department of Surgery, Malta, ²Mater Dei Hospital, Department of Pathology, Malta

Aims: Minimally invasive surgery is gradually becoming the mainstay of surgical treatment. In addition to the current mainstream four port cholecystectomy, current research has looked upon the possibility of a single incision laparoscopic cholecystectomy (SILC). In this meta-analysis we aim to compare conventional multiport laparoscopic cholecystectomy (CLC) versus single incision laparoscopic cholecystectomy in terms of operative time, cosmesis and post-operative pain.

Materials and Methods: A literature search was carried out on PubMed, MEDLINE,

EMBASE and Google Scholar, using MESH terms ‘randomised controlled trial’,’laparoscopy’, ‘single port’, ‘multi-port’ and ‘cholecystectomy’. Randomised controlled trials (RCT) comparing SILC versus CLC published between January 2010 and January 2021 were included. Data was collected on operative time, cosmesis and postoperative pain visual analog score (VAS) at 6 and 24 h.

Results: Seven randomised controlled trials were used. When compared to CLC, SILC has comparable operative time (Chi2 = 273.78; p < 0.0.00001; CI -2.19, 24.12; I2 98%) and VAS pain score at 6 h (Chi2 = 19.77; p < 0.0001; CI -0.49, 0.15; I2 = 90%). CLC had a significantly better cosmetic outcome (Chi2 = 16.07; p < 0.0003; CI 0.89, 1.38; I2 = 88%). SILC demonstrated a significantly better VAS pain score at 24 h (Chi2 = 45.15; p < 0.00001; CI -0.37, -0.02; I2 = 91%).

Conclusion: This meta-analysis demonstrated that with the exception of improved post-operative pain at 24 h, SILC did not show improved outcomes when compared to CLC. With the present published RCTs we are unable to provide statistical analysis on further outcomes such as post-operative complications. Hence the choice of procedure remains largely the decision of the operating surgeon.

HEPATO-BILIAIRY & PANCREAS—Liver

P096—Laparoscopic Resections for Klatskin Tumour—Three Cases

János Bezsilla ¹ , A. Berencsi¹, Z. Sipos¹, T. Balog¹, P. Gajdátsy¹

¹B-A-Z County Hospital, Surgical, Hungary

Surgical management of hilar cholangiocarcinoma remains the only treatment option with curative intent and potential influence on overall survival.

In our case series, we describe complete laparoscopic resection of Klatskin’s tumour which consists of radical extrahepatic biliary resection with lymphadenectomy and in selected cases with left hepatectomy followed by laparoscopic intracorporeal biliary reconstruction with Roux-en-Y hepaticojejunostomy.

Two women and a man aged 45 (28-59) years presented with obstructive jaundice without other symptoms. Their CEA, Ca-125, AFP values were normal and Ca 19-9 was elevated in only one case. CT, ERCP and MRCP showed Bismuth type II., III.b. and IV. neoplastic lesions, with vascular involvement in the third patient.

Diagnostic laparoscopy was performed with ultrasonography. Cholecystectomy with resection of the extrahepatic biliary ductal system and the transection of prestenotic central even the right biliary branch/branches was done. Hepatoduodenal lymphadenectomy was performed and in two cases left branches of the hepatic artery and the portal vein were clipped. In one case segment II-IV was removed without caudate lobectomy and in another case segment I-IV. In these operations left hepatic vein was clipped. After removal the specimen through a left upper quadrant minilaparotomy and construction a Roux-en-Y loop, bilioenteric anastomosis was performed using total laparoscopic procedure. In Bismuth type IV. case we created two separate bilioenteric anastomoses.

The operation time was 310 (255-440) minutes with intraoperative blood loss of 200 ml. The pathologic result showed one pT2 pN0 and two pT2 pN1 primary hilar cholangiocarcinomas with all resected margins free of tumour.

The postoperative hospital stay was uneventful and patients were discharged on day 13 (12-14).

Patients had adjuvant chemotherapy and were well at 3-month visit with normal results of liver function test and MRCP.

Laparoscopic resection and bilioenteric reconstruction are feasible surgical approaches in selected patients with hilar cholangiocarcinoma.

HEPATO-BILIAIRY & PANCREAS—Liver

P097—Survival After Laparoscopic and Open Liver Resection for Intrahepatic Cholangiocarcinoma: Non-matched Analysis of a Single Center Experience

Mikhail Efanov ¹ , M. Efanov¹, N. Britskaia¹, R. Alikhanov¹, I. Kazakov¹, A. Vankovich¹, D. Kovalenko¹, A. Koroleva¹, A. Olesya¹, V. Tsvirkun¹, I. Khatkov¹

¹Moscow Clinical Scientific Center, HPB Surgery, Russia

Introduction: The international experience of laparoscopic liver resection for intrahepatic cholangiocarcinoma (ICC) remain controversial. The aim of the study was to compare the short- and long-term outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for ICC.

Methods: The demographic and peri-operative data, short-term surgical outcomes, and long-term oncological results of patients who received liver resection for HCC between January 2014 and December 2020 were analyzed.

Results: The total number of patients underwent liver resection for ICC was 53. Survival was estimated in 39 patients. The outcomes of 9 LLR and 30 OLR were analyzed. The 4-year overall survival after LLR were significantly longer than after OLR (75% vs. 35%; p = 0.009).

Conclusions: LLR for ICC is a feasible procedure with promising survival in selected patients

HEPATO-BILIAIRY & PANCREAS—Liver

P098—Evaluation of the cytokine profile in patients with open and laparoscopic resections of metastatic liver disease

V. Kosyi¹, Dmitry Astakhov ², N. Akhmatova³, D. Astakhov², Y. Ivanov¹, D. Panchenkov⁴

¹Evdokimov Moscow State University of Medicine and Dentistry, surgical, Russia,²Evdokimov Moscow State University of Medicine and Dentistry, Laboratory of Minimally Invasive Surgery, Russia, ³Mechnikov Research Institute of Vaccines and Sera, Laboratory of Mechanisms of Immunity Regulation, Russia, ⁴Evdokimov Moscow State University of Medicine and Dentistry, Chair of Surgery and Surgical Technologies, Russia

Aims of the study is to evaluate the cytokine profile and innate immunity parameters in laparoscopic (LLR) and open resections (OLR) of liver metastases.

Methods: 30 patients with liver metastases were operated on in the volume (LLR) 14 patients and (OLR) 16 patients, the control group was 10 practically healthy test persons. Blood samples was carried out before the operation, after 6 h, 24 h and on the 7th day. The coefficient balance of Th 1/2, 1/9, 1/17, 1/22 and Th 2/9, 2/17, 2/22 was assessed by their cytokine profiles IL-1b, IL-2, IL-4, IL- 5, IL-6, IL-10, IL 17a, IL 22, IL 9. Statistical analysis was performed using the program Statistica 10. Statistical significance was determined by non-parametric Kruskal-Wallis test with Dunn's posterior test.

Results: In patients with cancer, cytokine levels are initially elevated before surgery compared with the control group. Open liver resections were characterized by a greater increase in the level of cytokines characteristic of Th9/Th17/Th22 helper cell subpopulations compared with laparoscopic operations and the control group.

Conclusion: When performing laparoscopic operations, the imbalance of the cytokine system of helper cells is significantly lower than with open resections.

HEPATO-BILIAIRY & PANCREAS—Liver

P099—Surgeon Performed Percutaneous Transhepatic Biliary Drainage- Our Experience

Neha Kumar ¹ , I. I. Sardiwalla¹, N. C. Kalenga¹, M. Z. Koto¹

¹Sefako Makgatho Health Sciences University, Hepatobiliary, South Africa

Introduction: Percutaneous transhepatic biliary drainage (PTBD) is an effective method to treat biliary obstruction especially in cases where endoscopic drainage modalities are unsuccessful. The main concern with PTBD is the high complication rate (up to 10% complication with a procedure related mortality rate of 0.8%). PTBD also needs to be performed by someone with the correct training, and this is usually an interventional radiologist. At our center, there is very limited access to interventional radiology, majority of PTBDs are performed by surgeons.

Methods: A retrospective review of a prospectively maintained database was carried out from January 2019- November 2021 was carried. All PTBDs performed at a single referral center (Dr George Mukhari Academic Hospital) were analysed. The procedures were analysed in two groups based on whether they were performed by the surgical team or the interventional radiologist to allow for direct comparison. Primary outcomes of interest were technical success and post procedure adverse events. Secondary outcomes of interest included clinical success and length of hospital stay. All complications were reported using the Clavien-Dindo scoring system.

Results: During the period specified, a total of 41 consecutive patients underwent PTBD. 33 (80%) patients had the PTBD performed by the surgical team and 8 (20%) patients has the procedure performed by interventional radiology. PTBD was successful in 39/41 patients (95%). The success rate was equivalent in procedures performed by the surgical team vs the radiology team (p = 0.61). In 11/41 patients (27%) procedure related complications were observed. Majority of the complications were Grade II (AKI) and seen in 22% of patients. Major complications (noted as Clavien-Dindo III and higher) occurred in 5/41 patients (12%). Procedures performed by surgical team had equivalent rates of complications compared to those performed by radiology team (4% vs 5%, respectively [p = 0.21]). With respect to the prosthesis related complications, particularly slipped drains, these occurred in 3/41 patients (7%).

Conclusion: Surgeon performed PTBD, in our setting, is a feasible option considering the resource limitations. The PTBD procedure has a high morbidity rate particularly regarding AKI in our patients with limited access to health care and resources.

HEPATO-BILIAIRY & PANCREAS—Liver

P100—A New Surgical Treatment Method for Liver Hydatid Cyst Treatment: Laparoscopic PAIR and Drainage

Ali Uzunkoy¹

¹A Education and Researh Hospital, General Surgery, Turkey

Aims: In the treatment of liver hydatid cyst, the imaging-guided PAIR (percutaneos aspiration injection and reaspiration) method has advantages such as avoiding the complications of general anesthesia and laparotomy. However, it is not possible to completely evacuate the contents of the cyst in the PAIR method The results of the patients who underwent surgery with this new technique developed by me in order to combine the advantages of both PAIR and laparoscopy are presented.

Methods: All of the cases were performed by a single surgeon between 2008 and 2021. This technique was applied to the cases that were not suitable for PAIR, had no contraindications for laparoscopic surgery, and were thought to be accessible cysts with a laparoscopic PAIR. Hospital records were evaluated retrospectively.

Technique: The gases with povidon iodine solution were placed around the cyst. The cyst content was evacuated with a percutaneously inserted Verres needle and hypertonic saline or povidone iodine solution was given into cyst cavity. After waiting, all the fluid was aspirated. The top of the cyst was punctured with the cautery with aspirator and aspirated cyst content. Camera was entered into cyst cavity, and all the residues were evacuated and investigated for bile leakage.. In cases with more than one cyst, this procedure was applied for each cyst. Perioperative ultrasonography was used in cysts that could not be seen laparoscopically. In cases that could not be reached with laparoscopic PAIR, the cyst content was aspirated intraabdominally.

Results: Fiftytwo cases who underwent laparoscopic PAIR and drainage were evaluated. There was more than one cyst in 36.5% cases. The procedure was completed laparoscopically in 96% of the cases. In 4% case with more than four multiple cysts was converted open surgical method. One case was evaluated as recurrence. The complication rate was 7.6% and no mortality was observed.

Conclusion: The laparoscopic PAIR method that I developed has the advantages of both laparoscopy and the PAIR method, and I believe that it is a safe method in the treatment of hydatid liver cyst, which is not particularly suitable for PAIR and has many cysts.

HEPATO-BILIAIRY & PANCREAS—Liver

P101—Complicated Liver Hydatid Disease—A Multimodal Approach

Elena Adelina Toma ¹ , O. Enciu¹, V. Calu¹, C. D. Piriianu¹, A. Miron¹

¹Elias Emergency Univeristy Hospital, General Surgery, Romania

The hydatid disease is a serious ailment caused by the parasite Echinococcus granulosus and can have multiple complication that can sometimes prove lethal. The parasite is usually found in endemic areas and the disease involves the liver in more than 75% of cases, but the cysts can be found almost anywhere in the body. Hydatid cysts are often asymptomatic and are in most cases discovered incidentally or in advanced stages of the disease due to complications arisen from metastases or rupture. Computed tomography (CT) remains the most valuable investigation for assessing complications and individual treatment planning. The surgical approach is open or, in selected cases, minimally invasive, while endoscopic retrograde cholangiopancreatography (ERCP) is an effective method of treatment for liver hydatid cysts with biliary fistulae.

This report presents a case of primary hydatid cysts located in the liver successfully treated by a tailored surgical approach, combining open and minimally invasive techniques and ERCP. An 18 year-old female patient with a giant hepatic cyst ruptured in the peritoneal cavity was admitted in the General Surgery Department with diffuse abdominal pain, but without any associated anaphylactic reactions. The patient exhibited non-specific clinical presentations and was submitted to several surgical procedures, minimally invasive combined with endoscopic procedures (billiary stent by ERCP) combined with antiparasitic agents. Follow-up at 6 months showed complete eradication of the parasite.

This case underlines the need for individually customized treatment in order to minimize the complications and successfully cure the disease.

HEPATO-BILIAIRY & PANCREAS—Liver

P102—Applying of Dynamic Laparoscopy at the Stages of Treatment Combat Trauma to the Abdomen

Oleh Herasymenko, I. Khomenko², O. Herasymenko¹, K. Muradian¹

¹Military Medical Clinical Center of the Southern Region of Ukraine, Department of Abdominal Surgery, Ukraine, ²General Military Clinical Hospital of Ukraine, Department of Abdominal Surgery, Ukraine

Introduction: In civil surgery the technique of dynamic laparoscopy is used. After operations that require re-examination "second look", in the anterior abdominal wall remains laparoport, through which further re-examination of the abdominal cavity. It allows to control the effectiveness of the previous operation. For all known methods of dynamic laparoscopy, conventional standard 10 mm laparoports are used. However, this technique is more suitable for inpatient conditions, for patients who do not require evacuation. The use of standard ports for the wounded, is impractical due to the possibility of complications during the evacuation, namely—damage to the abdominal organs by the trocar, pain during trocar movements. The use of dynamic laparoscopy in combat injuries of the abdomen at the stages of medical evacuation is not described in literature. When using a trocar, a number of significant disadvantages were identified: -the length of the trocar;—it is an inflexible rigid tube, which in case of uncontrolled movement can injure the organs;—causes pain when shifting body position;—limited ability to conduct re-examinations only with a laparoscope with a diameter of 10 mm;—Insufficient fixation in the anterior abdominal wall.

Aim: to improve the results of treatment of patients with combat trauma of the abdomen by using dynamic laparoscopy.

Materials and Methods: For dynamic laparoscopy in the wounded we used standard plastic laparoports in two cases of fragmentary liver injury and in case of gunshot fragmentation injury of the ascending colon. With firearms taken into consideration the above shortcomings, we have developed a method of dynamic laparoscopy for combat injuries of the abdomen at the stages of medical evacuation with a reliable, convenient, safe, universal laparoport of soft material. The port for dynamic laparoscopy is used as follows. At the end of laparoscopy or laparotomy for abdominal injuries, a silicone port remains in the puncture site in a convenient place for inspection, which is fixed in the anterior abdominal wall due to areas of expansion in the upper and lower parts. After the condition stabilizes, the wounded person is sent to the next levels of medical care, where, according to the indications, dynamic laparoscopy is performed. It is possible to use both a 10 mm and a 5 mm cameras.

Results and Conclusion: the effectiveness of the "method of dynamic laparoscopy for combat injuries of the abdomen" was confirmed in the treatment of 19 wounded (2—with standard laparoports, 17—with the silicone port), which avoided pain and risk of additional trauma to the abdominal organs, to conduct a re-audit of the abdominal cavity at the following levels of care. Widespread introduction of endovideosurgical technologies in the treatment of wounded with combat injuries at the II-IV levels of medical care has avoided unwarranted traumatic interventions, earlier activation of the wounded, reduce inpatient treatment and return the wounded to service earlier than traditional treatments.

HEPATO-BILIAIRY & PANCREAS—Liver

P103—Videoendoscopic Transpopillar and Endovascular Interventions in the Stage Treatment of Combat Liver Injuries

Yaroslav Haida ¹, K. Humenyuk², Y. Haida¹, O. Herasimenko¹, M. Kashtalian³, R. Yenin¹

¹Military Medical Clinical Center of the Southern Region of Ukraine, Department of Abdominal Surgery, Ukraine, ²General Military Clinical Hospital of Ukraine, Department of Abdominal Surgery, Ukraine, ³Odessa National Medical University of Ukraine, Abdominal Surgery, Ukraine

Introduction: the frequency of combat injuries to the abdomen in modern military combats ranges from 6.6% to 9%, of which liver injuries are about 21%; In the structure of modern combat injuries of the abdomen increases the proportion of liver injuries, which is accompanied by the development of severe bleeding, traumatic illness and high mortality (20.2-70.5%);

Aim: to improve the results of diagnosis and surgical treatment of wounded with gunshot wounds to the liver by combat trauma to the abdomen, through the use of minimally invasive technologies.

Materials and Methods: Clinical and statistical analysis of the results of treatment of 101 wounded with gunshot wounds to the liver, delivered from the area of Operation Joint Forces (Anti-Terrorist Operation), which were treated at II, II and IV levels of care during 2014-2019. All wounded were male, aged 18 to 54 years (average—32.6 + 1.7 years). Groups of wounded were divided in chronological order and depending on the methods of diagnosis and treatment used. The first group (comparison group) consisted of 47 wounded with gunshot wounds to the liver, received in the period 2014-2015, who were treated according to traditional tactics. The second group (main group) consisted of 54 wounded in the period 2016-2019, who used a comprehensive method of diagnosis and surgical treatment using minimally invasive techniques.

Research Results: Complications of the clinical course predominated in the comparison group—31 (66.0%) cases against 28 (51.9%) cases in the main group (p > 0.05). At thoracoabdominal injuries among complications Respiratory distress syndrome predominated—7 (14.9%) cases in the group comparison and 4 (7.4%) cases among the complications of the main group; pneumonia—8 (17.0%) and 6 (11.1%); exudative pleurisy—12 (25.5%) and 7 (13.0%), respectively. Development of RDS in the early post-traumatic period due to traumatic shock, lung injuries and concomitant diseases. In 4 (8.5%) cases in the postoperative period acute pancreatitis was observed in the wounded of the comparison group and in 4 (7.4%) cases in the wounded of the main group. Multiple organ failure was observed in 2 (4.3%) injured comparison groups, and in 1 (1.9%) wounded of the main group, accompanied by acute cardiac vascular, respiratory and renal failure. Of the 54 wounded in the main group, 4 (7.4%) died, including 1—2nd day—2 (3.7%), on the 3rd—7th day—1 (1.9%), on the 16th day and later—1 (1.9%). Of the 47 injured in the comparison group, 8 (17.0%) died, including on the 1st—2nd day—4 (8.5%), on the 3rd—7th day—2 (4.3%), on the 8th—15th day—1 (2.1%), on the 16th day and later—1 (2.1%).

Conclusions: Improved differentiated surgical tactics with the combined use of modern minimally invasive methods of surgical treatment of gunshot wounds of the liver avoided laparotomies in 15 (27.8%) cases of the main group (p < 0.001); reduced the number of postoperative complications from 78.7% in the comparison group to 59.3% in the main group (p < 0.05), relaparotomy in the wounded from 66 to 20.4% (p < 0.001), as well as the duration of treatment wounded from 42.4 + 2.7 to 32.2 + 1.4 bed-days (p < 0.001).

HEPATO-BILIAIRY & PANCREAS—Liver

P104—Needlescopic Cholecystectomy with 14-Gauge Assisting Instruments: A Technical Modification for Paediatric Ages

R. Shalaby¹, Abdelmoneim Shawky Shamseldin ¹, A. Elsaied², S. Shehata, M. Negm³

¹Al-Azhar University, Pediatric Surgery Deparment, Egypt, ²Mansoura University Hospital, Pediatric Surgery, Egypt, ³South Valley University, Quena, Pediatric Surgery, Egypt

Abstract: Objectives: This study aims to present needlescopic cholecystectomy (NC) using the 14-G Mediflex suture device (MSD) as an assisting instrument in pediatrics.

Patients and Methods: Needlescopic cholecystectomy was carried out on 48 children at 4 paediatric tertiary centres in Egypt The operation was performed using two MSDs 14-G in diameter as assisting instruments in addition to 3-mm working epigastric instruments and umbilical 5-mm or 10-mm port for 30° telescope. Through one working 5-mm or 10-mm port, the gallbladder was retrieved.

Results: A total of 48 patients with chronic calcular cholecystitis were subjected to NC. There were 35 females and 13 males with a median age of 7.29 years (range = 3–14 years). No conversion to other techniques was reported. The mean operative time was 47.69 ± 7.2 SD minutes [range = 35- 75 min]. The follow-up period was 18 months. The degree of cosmetic satisfaction of the parents was excellent, as reported by the parents’ satisfaction score.

Conclusion: Needlescopic cholecystectomy using MSDs and 3-mm instruments is a new technical modification of minilaparoscopic cholecystectomy that is feasible and reproducible and has a good cosmetic result.

HEPATO-BILIAIRY & PANCREAS—Liver

P106—Use of Single-port Technique for Laparoscopic Liver Resections—Slovenian Experience

Jerica Novak ¹ , B. Trotovšek¹, M. Đokić¹

¹University Medical Centre Ljubljana, Department of Abdominal Surgery, Slovenia

Aim: Single-port laparoscopic hepatectomy is an emerging surgical modality for the treatment of the benign and malignant liver lesions. Due to the methods technical challenges it is suitable for experienced hepatobilliary surgeons in selected group of patients. The aim of this study was to evaluate the results of a single Slovenian centre performing single-port laparoscopic hepatectomy.

Methods: A single centre retrospective consecutive case series of the eleven patients with liver disease operated with the single-port technique form January 2018 to April 2021 at the Department of the Abdominal Surgery in the University Medical Centre Ljubljana was performed. Lesions were chiefly located in the left lateral section or sixth liver segment. The operative time, conversion rate, length of the hospital stay and surgical complications were recorded and evaluated.

Results: We performed eleven single-port liver hepatectomies (median age 63, range 31 to 79 years). Mean operative time was 97 min. None of the cases was converted to multi-port laparoscopic or open surgery. Safe resection margins were obtained in case of malignant disease. The mean hospital stay was 4 days. No major surgical complication or morbidity were noted.

Conclusions: The single-port laparoscopic hepatectomy is a safe and feasible technique for the operation of benign and malignant liver lesions in hands of skilled and well trained surgeons.

HEPATO-BILIAIRY & PANCREAS—Liver

P107—Laparoscopic Operations in a Treatment of Patients With Bleeding from Varicose Veins of the Stomach with Cirrhosis of the Liver

Yurii Grubnik ¹ , V. Fomenko¹, O. Yuzvak¹, M. Grubnik¹

¹Odesa National Medical University, Surgery Department №3, Ukraine

Aim: To reduce mortality and morbidity in patients with cirrhosis of the liver from bleeding varicose veins of the stomach due to laparoscopic operations in combination with endoscopic hemostasis.

Methods and materials: 97 patients with cirrhosis of the liver with bleeding from varicose veins of the stomach were treated under the supervision in the last 5 years. Out of these, in 59 patients bleeding from the veins of the stomach was combined with bleeding from the veins of the esophagus. in 86 patients local endoscopic hemostasis was performed with ligation of varicose veins of the esophagus and stomach using rubber bands “Boston Scientific” according to the method of Stiegmann—Goff. Danish stent was used to stop bleeding in 17 cases. In 21 cases, endoscopic injection of “Immuno” fibrin glue was performed para- and intravasal. After stopping bleeding, laparoscopic fundus and body of the stomach resections were performed in 38 cases. In 59 cases, repeated endoscopic hemostasis was performed after 1,3,6 months.

Results: Out of 38 patients who underwent laparoscopic resections of the fundus and body of the stomach: in 4 cases, recurrent bleeding was observed after 6 months, which was stopped by the use of endoscopic hemostasis in 2 cases, in other 2 cases patients died. In 2 cases, a subphrenic abscess was observed, which was punctured under ultrasound control. In 59 cases where endoscopic prolonged hemostasis were performed, we observed a relapse in 21 patients. In 12 cases, it was possible to stop bleeding by the endoscopic method. 9 patients died.

Conclusions: The use of laparoscopic operations in patients with varicose veins of the stomach decreased mortality from 15 to 6 percent (%).

HEPATO-BILIAIRY & PANCREAS—Liver

P108—The Laparoscopic Management of Large Simple Hepatic Cyst

Israel de-Alba Cruz ¹ , V. A. Arcenio Luis¹, S. A. Silvia Jacqueline¹, Y. C. Castillejos¹, V. F. Julian¹, J. L. Amador¹, D. R. Jorge Alejandro¹, S. L. Juan¹, N. G. Hugo Fernando¹, L. V. Angel Javier¹, S. B. Ana Laura¹, A. O. Orlando¹, C. C. Pabel Ruben¹, L. P. Emma Berenice¹, T. Andrea¹, G. S. Lourdes Gisele¹

¹General Ignacio Zaragoza, Surgery, Mexico

Cystic lesions of the liver represent a heterogeneous group of disorders, which differ in etiology, prevalence, and clinical manifestations. Most liver cysts are found incidentally on imaging studies and tend to have a benign course. A minority can cause symptoms and rarely may be associated with serious morbidity and mortality. Larger cysts are more likely to be symptomatic and cause complications such as spontaneous hemorrhage, rupture into the peritoneal cavityor bile duct, infection, and compression of the biliary tree. Specific types of hepatic cysts may have unique complications such as malignant transformation in the case of a mucinous cystic neoplasm or a ciliated hepatic foregut cyst, or anaphylactic shock due to a hydatid cyst. Some of these complications may occasionally mandate surgical intervention.

Methods: 72 years old male patient who presents with transfictive abdominal pain in upper left quadrant, abdominal distention, fever and malaise with a palpable tumor in most of the upper abdomen, which is painful, with no evidence of peritoneal irritation. Ultrasound and CT revealed a giant hepatic cyst. Laparoscopy was performed finding irregular cystic liver tumor aspirating 800 mL of seropurulent material, there where no complications, The postoperative outcome was uneventful as the patient made a full recovery.

Results: Even though most of the hepatic cysts are benign, better to undergo investigations such as CT, Histopathology examination to rule out differential diagnosis and to alleviate any further complications.The treatment for this entity is not yet well established, laparoscopic surgery has brought good results for the resolution of hepatic cysts, however, there have been technical difficulties principally in cysts located in deep or posterior segments.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P109—Pancreatic Fistula Prediction Scale for Laparoscopic Pancreatoduodenectomy

Mikhail Mikhnevich ¹ , I. Khatkov¹, R. Izrailov¹, O. Vasnev¹, A. Andrianov¹, P. Tiutiunnik¹, M. Baychorov¹, P. Agami¹

¹Moscow Clinical Scientific Center, High-tech Surgery and Surgical Endoscopy, Russia

Aims: Despite advancements in surgical technic and improvements in perioperative management, postoperative clinically relevant pancreatic fistula (POPF) remains the most life-threatening complication after laparoscopic pancreatoduodenectomy (LPD). Attempts for reinforcement of high-risk pancreatic anastomoses didn’t show statistically significant decrease in POPF rate. Therefore POPF-prediction become the most promising method for POPF-prevention. Prediction results were compared to updated alternative fistula risk score (UA-FRS) prognosis.

Methods: We established post pancreatoduodenectomy fistula risk scale (PP-FRS) derived from a retrospective cohort (n = 78). Pancreatic density for the supposed resection line was estimated using preoperative CT (CT-density during delay phase, CT-attenuation coefficient) and intraoperative palpation scoring (0–4, where 4 score corresponds the firmest parenchyma). These risk factors afforded 6-points prediction model, where 5 and 6 points corresponds a high-risk patient. PP-FRS was validated retrospectively. ROC-AUC and Kendall rank correlation coefficient were compared with UA-FRS prediction results for the same cohort.

Results: CR-POPF occurs in 25% cases (9%—Grade B, 16%—Grade C). ROC-AUC for PP-FRS and UA-FRS was 0.793 and 0.891, respectively. Risk scores strongly correlated with fistula development (p < 0.01). Kendall coefficient was 0.429 and 0.498 for PP-FRS and UA-FRS, respectively.

Conclusions: A simple 6-points PP-FRS accurately predicts the risk of CR-POPF after LPD. This can be helpful during preoperative counseling, regarding the amount of planned surgical treatment (pancreatic resection or pancreatectomy); intraoperative mitigation strategy (external pancreatic stenting, refusing somatostatin analogues). While planning a clinical trial PP-FRS can distinguish high-risk patients to form homogeneous comparing groups.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P110—Pancreatic Stump Reinforcement with Falciform Ligament during Laparoscopic Distal Pancreatectomy

Pavel Tyutyunnik ¹ , Khatkov, Tsvirkun¹, Izrailov, Andrianov¹, Mikhnevich, Baychorov¹, Agami, Salimgereeva¹

¹Moscow Clinical Scientific Center, High-tech Surgery and Surgical Endoscopy, Russia

Purpose: Pancreatic fistula (PF) is the most common and dangerous complication after distal pancreatectomy (DP). The most effective technique of pancreatic stump closure still unclear. Here, we aimed to compare the efficiency of implementation of falciformed ligament (FL) pancreatic stump closure techniques for preventing PF during laparoscopic DP.

Methods: All patients between November 2014 and February 2021 who had laparoscopic DP with pancreatic stump covered with FL or no FL covered was retrieved. Their intra- and postoperative outcomes (Operative time, blood loss, length of hospital stay, postoperative complication according to Clavien-Dindo) were compared.

Results: A total of 118 patients were included. Group A—23 patients with pancreatic stump peirnforcement with FL and group B 95 patients without pancreatic stump reinforcement with FL. Median operative time was 260 (165–510) and 247,5 (range 155–535)min, in group A and B, respectively. and median blood loss was 100 (range 5—1000) and 100(range 20–300)ml, in group A and B, respectively. Postoperative stay 8(5–40) days and 9,5(6–38) days (P = 0.590) in group A and B, respectively. Postoperative pancreatic fistula (PPF) grade B occurred in 30% (n7) vs 27%(n26), (P > 0.005) and grade C occurred in 0% vs 3%(n3) P = 0.005, in group A and B, respectively.

Conclusion: Pancreatic stump reinforcement with falciformed ligament during laparoscopic distal pancreatectomy is safe and feasible procedure. Prospective multi-centric trials are needed for further evaluation of the technique.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P111—Laparoscopic Operations in Patients with Chronic Pancreatitis

Aleksey Andrianov ¹ , R. E. Izrailov¹

¹Moscow Clinical Stientific Center, Hi-tech Surgery, Russia

Aim: To demonstrate the experience of laparoscopic operations (longitudinal pancreatojejunostomy, Frey and Beger procedure).

Materials and Methods: From January 2014 to January 2021 laparoscopic longitudinal pancreatojejunostomy, Frey and Beger procedure were performed in 67 patients (46 (68.7%) male, 21 (31.3%) female) with chronic pancreatitis type C (classification of M.Buchler). The age of the patients was 48 (21–68) years. The size of the pancreatic head was 48 (16–69) mm, the diameter of the main pancreatic duct was 8 (4–14) mm.

Results: The operating time was 390 (190–680) minutes. Blood loss was 150 (30–800) ml. Conversion was required in 5 (7.4%) cases. Complications developed in the post-operative period in 13 (20.9%) patients. The length of postoperative stay period was 4 (3–28) days. The follow-up ranged from 2 to 80 months Pain relief was complete in 62 (92.5%) patients.

Conclusions: The short-time outcomes shows that laparoscopic operations (longitudinal pancreatojejunostomy, Frey and Beger procedure) for the chronic pancreatitis are safe and feasible.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P112—Comparison of the Clinically Relevant Pancreatic Fistulas Prediction Models After Laparoscopic Pancreatoduodenectomy

Magomet Baychorov ¹ , I. Khatkov¹, R. Izrailov¹, O. Vasnev¹, P. Tytyunnik¹, A. Andrianov¹, M. Mikhnevich¹, P. Agami¹, D. Salimgereeva¹

¹Moscow Clinical Scientific Center, High-tech Surgery, Russia

Introduction: different models were proposed to predict clinically relevant postoperative pancreatic fistula (CR-POPF) development after open pancreatoduodenectomy. Among them are the Fistula Risk Score (FRS), Alternative Fistula Risk Score (a-FRS), Updated Alternative Fistula Risk Score (ua-FRS), Japanese Fistula Risk Score (JFRS). External validations of these scales applying to laparoscopic procedure should be performed.

Purpose: Is to perform external validations of different scales of prediction CR-POPF after LPDE.

Methods: From 2007 to 2018, 290 LPDEs were performed at single institution. The individual risk scores according different scales were calculated for each patient, and clinical outcomes were evaluated. Receiver operator curve analysis was performed to judge model validity..

Results: Out of 290 patients, 60 (20,7%) developed CR-POPF (15,9% grade B, 4,8% grade C). The incidences of CR-POPF in patients classified as negligible risk, low risk, intermediate risk, and high-risk by original-FRS were 4%, 8.2%, 26%, and 45%, respectively. The area under the ROC curve (AUC) was 0.745 for a-FRS vs. 0.70 for original-FRS. The incidences of CR-POPF in patients classified as low risk, moderate risk, and high-risk by a-FRS were 7,5%, 23,9%, and 44%, respectively. The AUC was 0.748. In patients who developed CR-POPF the mean ua-FRS score was 43,5% ± 21,9 vs 23,9% ± 18,7 for patients who did not suffer from CR-POPF (p < 0,0001). The AUC for ua-FRS was 0,772. The AUC of J-FRS, which was originally developed for the prediction of grade C POPF, was 0,692, showing low predictive value of this scale for LPDE.

Conclusion: The ua-FRS appears to be the most accurate and convenient tool for predicting occurrence of CR-POPF after LPDE.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P113—Laparoscopic Approach of Acute Pancreatitis Collections: A Serie of Cases

Emil Ioan Mois ¹ , F. Graur¹, P. Pop¹, D. Popa¹, S. Moldovan¹, L. Furcea¹, C. Puia¹, C. Popa¹, F. Zaharie¹, N. Al Hajjar¹

¹Regional Institute of Gastroenterology and Hepatology, General Surgery, Romania

Aim: Acute pancreatitis (AP) represents the main cause for over 50% of all hospital admissions for pancreatic disease and it is known as one of the most unpredictable affections of the digestive system. Moderate severe or severe pancreatitis occurs in about 15-20% of patients who can further develop local (necrosis) or general complications. Pancreatic or peripancreatic necrosis can become over-infected, which is responsible for a high mortality rate. These collections can be managed by minimally invasive techniques as percutaneous, endoscopic or laparoscopic dreinage. The purpose of this presentation is to point out favourable outcomes of a laparoscopic approach in collections due to AP.

Methods: We present a serie of 5 cases of acute pancreatitis, mostly of associated with pancreatic or peripancreatic over-infected collections which presented to the Regional Institute of Gastroneterology and Hepatology Cluj-Napoca, Romania, between 2019-2021. All of these cases were managed through a laparoscopic approach.

Result: The AP can be often caused by gallstone migrations or can be determined by alchohol abuse. In these particular cases the prevalent etiology was the biliary lithiasis. However, there is one case of AP with undefined etiology.

Conclusions: Effective management of AP is crucial and requires accurate diagnosis and treatment. These cases sustain the fact that a minimally invasive step-up approach is superior to primary open surgery for peripancreatic fluid collections.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P114—Should Serum Ca125 be Used in Clinical Practice as Predictive Markers of Survival in Pancreatic Ductal Adenocarcinoma?

Niccolò Napoli ¹ , E.F. Kauffmann¹, M. Ginesini¹, C. Gianfaldoni¹, A. Salomone¹, F. Vagelli¹, M. Vimercati¹, M. Caradonna¹, D. Daniela², F. Vistoli¹, U. Boggi¹

¹University of Pisa, Division of General and Transplant Surgery, Italy, ²University of Pisa, Division of Patology, Italy

Introduction: Carbohydrate antigen 125 (CA 125) encoded by mucin 16 (MUC16) and up-regulated by KRAS/ERK axis (Mol cancer Res, 2017) is emerging as a new serum marker of poor prognosis in pancreatic ductal adenocarcinoma (PDAC) (Oncotarget, 2016), probably promoting pancreatic cancer cell motility and development of distant metastasis (Sci Rep, 2013). Nevertheless, it appears strange that this marker has not yet been extensively introduced into clinical practice to evaluate the survival of patients with PDAC. To further investigate this role, herein we evaluated its ability to predict survival in our patient underwent surgical resection for PDAC, taking into account the stage of neoplasm.

Methods: Data regarding patients with PDAC underwent pancreatic resection at our institution between 2010 and 2016 were prospectively collect and retrospectively analyzed. Only patients with all preoperative and follow-up data available were considered. Patients operated before 2010 were excluded due to the lack of effective neoadjuvant therapies for locally advanced PDAC. Patients operated after 2016 were excluded due to the short duration of follow-up. Kaplan-Meier curve and Log-rank test were used to evaluate the overall survival (OS) in patient with standard (S-PDAC), borderline (BR-PDAC) and locally advanced (LA-PDAC) PDAC. Cox proportional-hazard regression was used to evaluate the role of CA125 in predicting survival. The last value of CA125 before surgery was considered.

Results: We considered 188 patients with PDAC underwent to pancreaticoduodenectomy (n = 118; 62.8%) and total pancreatectomy (n = 70; 37.2%). Seventy-three (38.8%) S-PDAC (localized to the pancreas), 87 (46.2%) BR-PDAC and 28 (14.9%) LA-PDAC were included. The median OS was 22.1 (10.3-61), 19.7 (11.1-44.6) and 16.4 (8.1-50.5) months in the S-PDAC, BR-PDAC and LA-PDAC (p = 0.75), respectively (Fig. 1). Preoperative serum level of CA125 predicted survival in patient with BR-PDAC (RR = 6.17, IQR = 1.20-22.4, p = 0.01) and LA-PDAC (RR = 18.7, IQR = 2.42-123.1, p = 0.003), but not in S-PDAC (RR = 4.53, IQR = 0.57-18.26, p = 0.13).

Conclusions: In our patient cohort serum level of CA125 predicts OS in BR-PDAC and LA-PDAC, but not in S-PDAC. Probably, in the first two groups the up-regulation of CA125/MUC16 favors the onset of distant micro-metastases, which lead to a poor long-term prognosis despite the effective neoadjuvant chemotherapy and the radical surgery. In the latter group, this pattern fails to affect prognosis with the same significance. Even if these results need to be confirmed in large series, they suggest as the serum level of CA125 should be introduced extensively into clinical practice of PDAC.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P115—Interventional Sonography for the Diagnosis of Pancreatic Disease

Karen Muradian ¹ , M. Kashtalian¹, Y. Haida¹, V. Shapovalov¹, A. Chertilina-Muradian²

¹Military Medical Clinical Center of the Southern Region of Ukraine, Abdominal Surgery, Ukraine, ²Odrex, Ultrasound, Ukraine

Introduction: The level of oncological diseases is constantly growing all over the world. Therefore, early diagnosis and treatment of oncological diseases is a top priority for medical institutions.

Aim: Improving the results of oncological diseases diagnostics by introducing the pancreatic neoplasm ultrasound-guided biopsy technique.

Materials and Methods: A clinical and statistical analysis of the results of diagnosing pancreatic neoplasms was carried out in 106 patients treated at the Military Medical Clinical Center of the Southern Region of Ukraine in the period from 2014 to 2021. Patients with pancreatic neoplasms in the comparison groups underwent minimally invasive diagnostic operations: ultrasound-guided percutaneous fine-needle aspiration biopsy—13, ultrasound-guided percutaneous core-needle biopsy—56, biopsy during diagnostic laparoscopy—37.

Results: According to the results of histopathological examination, in 85 (80.2%) cases, signs of carcinoma or ductal carcinoma of the pancreas of varying degrees of differentiation were revealed, in 21 (19.8%) cases, the morphological picture was characteristic of indurative pancreatitis without signs of a malignant neoplastic process. In 6 cases, upon receipt of a pathological and histological conclusion as a benign process (when CT signs of a malignant neoplasm of the pancreas were found), an additional biopsy was performed at other points. In all cases, the diagnosis—pseudotumorous pancreatitis was confirmed again by histopathological examination and immunohistochemical examination, which in turn influenced the choice of further treatment tactics for patients. In 23 cases, chemotherapy after a biopsy of a pancreatic neoplasm, followed by an immunohistochemical study and detection of sensitivity to chemotherapy drugs, was the final amount of treatment. In other cases, when a malignant formation of the pancreas was detected, surgical treatment of varying severity was performed. In 100% of cases, the histopathological conclusion of the postoperative material coincided with the results of biopsy. There were no complications during the procedures of biopsy.

Conclusions: Ultrasound-guided percutaneous core-needle biopsy is a safe minimally invasive procedure and is highly informative and effective in the treatment of patients with pancreatic diseases. This method helps to reduce the number of more traumatic diagnostic methods that require hospitalization and general anesthesia, which leads to the fastest recovery of patients.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P116—Palliative laparoscopic Roux-en-Y Choledochojejunostomy as a Feasible Treatment Option for patients with Malignant Distal Biliary Obstruction

Eun Young Kim ¹

¹Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Division of Trauma and Surgical Critical Care, Department of Surgery, Korea

Background: In patients suffering from distal biliary obstruction due to advanced periampullary cancer, the advantages of surgical bypass include high stent patency and low incidence of recurrent biliary obstruction. However, its use is limited due to the high invasiveness of the operation. Herein, we present the clinical findings of patients who underwent laparoscopic Roux-en-Y choledochojejunostomy (LRYCJ) compared with those who underwent endoscopic stent.

Material and Methods: From January 2015 to May 2021, we retrospectively reviewed the clinical outcomes of palliative care for malignant bile duct obstruction according to the type of intervention: LRYCJ versus endoscopic stenting. The occurrence of recurrent biliary obstruction (RBO) and clinical outcomes were reviewed, and the factors predisposing to RBO after initial intervention were identified via multiple regression analysis.

Results: The final analysis included 28 patients treated with LRYCJ (22.4%) and 97 patients who underwent endoscopic stent (77.6%). The two groups did not differ in the incidence of early or late complications as well as mortality. However, the LRYCJ group showed a lower incidence of RBO (4 patients, 14.3% versus 73 patients, 75.3%, p < 0.001). As a predisposing factor for RBO, endoscopic stenting was the only highly significant predictor (OR 16.956, CI 5.140-55.935, p < 0.001).

Conclusions: LRYCJ represents an attractive option for palliative treatment of malignant distal biliary obstruction, with improved biliary-tract patency and fewer subsequent interventions such as additional stenting, especially in cases with a relatively long life expectancy greater than 6 months.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P117—Percutaneous Endoscopic Necrosectomy of Walled-off Pancreatic and Peripancreatic Necrosis

Mateusz Jagielski ¹ , J. Piątkowski¹, M. Jackowski¹

¹Collegium Medicum, Nicolaus Copernicus University, Department of General, Gastroenterological and Oncological Surgery, Poland

Aims: In recent decades we observe constant development of minimally invasive techniques of treatment of consequences of acute necrotizing pancreatitis. The choice of access to the necrotic collection should mainly depend of localization of necrotic changes and experience of the medical center. Prospective assessment of efficiency and safety of innovative method of percutaneous necrosectomy in the treatment of patients with symptomatic walled-off pancreatic and peripancreatic necrosis.

Methods: 186 consecutive patients with symptomatic walled-off pancreatic and peripancreatic necrosis treated in the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland between 2018 and 2021 were included. The analyzed patients were treated with novel method of endoscopic percutaneous necrosectomy, in which percutaneous access to the necrotic collection was achieved with use of retroperitoneal route; consequently, the access was widened and self-expanding metal stent was placed percutaneously, which allowed to introduce the endoscope percutaneously into necrotic area and to perform endoscopic necrosectomy.

Results: In 13/186 (6.99%) patients with symptomatic walled-off pancreatic and peripancreatic necrosis an additional percutaneous drainage was performed during the endotherapy. In 7/13 (53.85%) patients (2 females and 5 males; average age 46.72 [31-65] years) were qualified to percutaneous endoscopic necrosectomy. Average size of the necrotic collection was 24.88 (15.24-32.5) cm. An active percutaneous drainage during transmural endoscopic drainage lasted 15 (11-31) days. Average number of procedures of percutaneous endoscopic necrosectomy was 3.67 (2-7). Complications of treatment were stated in 2/7 (28.57%) patients. Clinical success was achieved in 6/7 (85.71%) patients. Log-term success was stated in 6/7 (85.71%) patients.

Conclusion: Percutaneous endoscopic necrosectomy during transmural endoscopic drainage of walled-off pancreatic and peripancreatic necrosis is an effective method of minimally invasive treatment.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P118—Endotherapy of Pancreaticopleural Fistulas: A Single-Center Experience

Mateusz Jagielski ¹ , J. Piątkowski¹, M. Jackowski¹

¹Collegium Medicum, Nicolaus Copernicus University, Department of General, Gastroenterological and Oncological Surgery, Poland

Aims: Pancreaticopleural fistula is a serious complication of acute and chronic pancreatitis. Assessment of efficacy of various endoscopic techniques in treatment of patients with pancreaticopleural fistula.

Methods: Prospective analysis of endoscopic treatment of all consecutive 22 patients with pancreaticopleural fistulas in the course of pancreatitis in years 2018-2021 in the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland.

Results: In 22 patients (21 males, 1 female; average age 49,52 [30-67] years) with pancreatitis pancreaticopleural fistulas were diagnosed. In 19/22 (86.36%) patients fistula communicated with left pleural cavity; in 3/22 (13.64%) patients with right pleural cavity. In all 22 cases drainage of pleural cavity was performed. Chronic pancreatitis was recognized in 14/22 (63.64%) cases. In 15/22 (68.18%) patients with pancreaticopleural fistulas symptomatic pancreatic and peripancreatic collections (PPFCs) were diagnosed (11 patients with pseudocyst and 4 patients with walled-off pancreatic necrosis). In 21/22 (95.45%) cases endoscopic retrograde pancreatography (ERP) was performed, during which the presence of fistula was confirmed. In all 21 patients endoscopic sphincterotomy with stenting of main pancreatic duct was performed (passive transpapillary drainage). In 1/22 (4.55%) patient active treansmural drainage of pancreaticopleural fistula was performed due to inflammatory infiltration of peripapillary area preventing performance of ERP. Additionally, in all 15 patients transmural endoscopic drainage of PPFCs was performed. Clinical success was achieved in 21/22 (95.45%) cases. Total endotherapy period was average 191 (88-712) days. Long-term success in endoscopic treatment of pancreaticopleural fistulas was stated in 19/22 (86.36%) patients.

Conclusion: Endoscopic treatment of post-inflammatory pancreaticopleural fistulas is an effective method of treatment.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P119—The Use of Antibiotics in Endoscopic Drainage of Pancreatic and Peripancreatic Fluid Collections as Consequence of Pancreatitis

Mateusz Jagielski ¹ , W. Kupczyk¹, J. Piątkowski¹, M. Jackowski¹

¹Collegium Medicum, Nicolaus Copernicus University, Department of General, Gastroenterological and Oncological Surgery, Poland

Aims: Assessment of the role of antibiotics in endoscopic transmural drainage of post-inflammatory pancreatic and peripancreatic fluid collections (PPPFCs).

Methods: Randomized trial covering study group of 62 patients treated endoscopically due to PPPFCs in 2020 in our medical center. The first group consisted of patients who were receiving empirical intravenous antibiotic therapy during endotherapy. The second group consisted of patients without antibiotic therapy during endoscopic drainage of PPPFCs.

Results: 31 patients were included into the first group (walled-off pancreatic necrosis [WOPN]- 51.6%, pseudocyst-48.4%) and 31 patients into the second group (WOPN-58.1%, pseudocyst- 41.9%) (p = NS). Infection of PPPFCs content was stated in 16/31 (51.6%) patients from the first group and in 14/31 (45.2%) patients from the second group (p = NS). Average time of active drainage in the first group was 13.0 (6-21) days and in the second group—14.0 (7-25) days (p = NS). Total number endoscopic procedures on one patients was on average 3.3 (2-5) in the first group and 3.4 (2-7) in the second group (p = NS). Clinical success of endotherapy of PPPFCs was stated in 29/31 (93.5%) patients from the first group and in 30/31 (96.8%) patients from the second group (p = NS). Complications of endotherapy in the first group were stated in 8/31 (25.8%) patients and in 10/31 (32.3%) patients in the second group (p = NS). Long-term success was stated in 26/31 (83.9%) patients in the first group and in 24/31 (77.4%) patients in the second group (p = NS).

Conclusion: No antibiotic therapy is required in cases of efficient endoscopic transmural drainage of sterile and infected PPPFCs.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P120—A Five Year Analytic Retrospective Study of Pancreatic Cystic Neoplasm

Mostafa Refaie Abdelatty Elkeleny ¹ , H. el Hadad¹, M. Kasem², M. Saleh³

¹Faculty of Medicine,Alexandria University, General Surgery Department, GIT Unit, Egypt, ²Alexandria University, General Surgery Department, Egypt, ³Alexandria University, General Surgery, Tanzania

Background: Pancreatic cystic neoplasms (PCNs) are rare disease of the pancreas with varying imaging characteristic and great histological heterogeneity varying from benign, premalignant to overt malignant lesions.

Aim: to evaluate the prevalence and types of PCNs, analyzing their clinical characteristics, surgical managements, and outcome post resection.

Methods: this is a retrospective study enrolled 20 patients diagnosed with PCNs at gastrointestinal surgical unit at Alexandria Main University Hospital between January 2015 and December 2019.

Results: In the period evaluated, 20 cases of PCNs were identified and 70% of them were females with the average age at diagnosis of 51 ± 17.1 (range 20-75). Regarding clinical presentations, 90% of the patients were symptomatic with the most common symptom being abdominal pain. Surgical resections were performed in 90% of the patients based on the location of the cysts. Distal pancreatectomy with or without splenectomy was the most common type of surgery performed accounting for 61.1%. Others were pancreaticoduodenectomy in 17%, total pancreatectomy in 11% and enucleation 11%. Intraductal papillary mucinous neoplasm was the most common histological type of PCN accounting for 35%, followed by solid pseudopappilary neoplasm 30%, mucinous cystic neoplasm 25% and serous cystic neoplasm 15%. Regarding post-operative outcome, at least half of the patients experienced one or more post-operative complications, the most common being delayed gastric emptying. Other complications were intraperitoneal collections, chest infection, post-operative pancreatic fistula and exocrine/endocrine pancreatic insufficiency.

Conclusion: At present IPMNs are the most prevalent diagnosed PCNs with notable increase in the frequency of SPEN compared with other types of the cysts that were diagnosed in high frequency at the past. Surgical management is indicated for all symptomatic cysts and cysts suspicious of malignancy

HEPATO-BILIAIRY & PANCREAS—Pancreas

P121—Early Biliary Fistula After Pancreatoduodenectomy as a Cause of Morbidity and Mortality: Literature Review and Personal Experience

S. Motelchuk¹, Oleksandr Usenko ² , V. Kopchak³, O. Lytvyn⁴, P. Ohorodnyk⁵, S. Motelchuk¹

¹Shalimov National Institute of Surgery and Transplantology, Department of Pancreatic and Bile Ducts Surgery, Ukraine, ²Shalimov National Institute of Surgery and Transplantology, Head of the Department of Gastrointestinal Surgery, Ukraine, ³Shalimov National Institute of Surgery and Transplantology, Head of the Department of Pancreatic and Bile Ducts Surgery, Ukraine, ⁴Shalimov National Institute of Surgery and Transplantology, Department of Pancreatic and Bile Ducts Surgery, Ukraine, ⁵Shalimov National Institute of Surgery and Transplantology, Scientific researcher of the Department of Pancreatic Surgery and Bile Ducts Surgery, Ukraine

Purpose: This study focused on the assessment of morbidity, prognostic factors and treatment of early biliary complications, including stricture of biliary enterostomosis, transient jaundice, failure of hepaticojejunostomy and cholangitis.

Materials and Methods: Patients were distributed as follows: 1) patients without postoperative fistula complications, 2) patients with pancreatic fistula; 2) with biliary fistula and 4) patients with a combination of biliary and pancreatic fistula. Pancreatic fistula was identified according to the international definition—as a fluid with an amylase level exceeding three times the upper limit of normal serum value for 3 postoperative days. Biliary fistula, considered as bile leakage, by drainage with bilirubin levels exceeding three times the upper limit of serum level after the 3rd postoperative day or contrast diagnostic study, including percutaneous transhepatic cholangiogram, cholangiogram, interstitial tube or cholangiogram via drainage between the extrahepatic biliary system with the peritoneum. Exclusion criteria included the presence of enriched amylase fluid from the level of amylase drain. For combined pancreatic-biliary fistulas, we used the same definition as for isolated bile but with the presence of amylase-enriched drainage fluid.

Results: Data from 421 patients were collected retrospectively. During the period from November 2009 to December 2019, 421 pancreatoduodenal resections were performed in patients with malignant and benign tumors of the periampullary zone and complicated forms of chronic pancreatitis. Indications for traffic were adenocarcinoma (45%, n = 189), intraductal papillary mucinous neoplasia (21%, IPMN, n = 88), endocrine tumor (10%, n = 42), ampullary carcinoma (8%, n = 34)), carcinoma of the bile ducts (6%, n = 25), chronic pancreatitis (4%, n = 17), carcinoma of the duodenum (2%, n = 8) and others (4%, n = 18). Preoperative biliary drainage was established in 31% (n = 130) of patients, and bacterial culture of bile was positive in 35% (n = 147) of cases. At the time of surgery, 49% (n = 206) of patients had jaundice. The diameter of the common bile duct was 5 mm in 24% (n = 101) of patients. Hepaticojejunostomy was performed using nodal, continuous sutures or mixed method in 41% (n = 173), 11% (n = 46), and 48% (n = 202) patients, respectively.

Of the 421 patients, 10 (3%) had bile with GEA, 92 (22%) had pancreatic fistula, 105 (25%) had DGE, and 2 had combined GEA and PEA deficiency (3.5%). and (72%) patients without signs of anastomotic failure. There were 219 men (52%), 202 women (48%), aged 35 to 80, the average age was 61 + 9.3 years.

The mortality rate was 4% (n = 17). The causes of death were surgical complications in 62% (n = 11, including 2 ischemic complications, 4 pancreatic fistulas and 5 hemorrhages), cardiopulmonary disorders in 23% (n = 4) and various complications in 15% (n = 2).

Risk factors for early biliary complication: sex, benign neoplasm, malignant neoplasm, gatekeeper preservation method, common bile duct diameter < 5 mm, pancreatic fistula and use of 6/0 threads for biliary anastomotic sutures were associated with early biliary complications. All strictures of hepaticojejunostomy occurred in patients with a diameter of FF < 5 mm. Another factor associated with stricture in the analysis of the results was the use of suture material 6/0. With regard to transient jaundice, the only significant identified risk factor was the diameter of the LV < 5 mm. Cholangitis was much more common in benign or malignant neoplasms.

Conclusions: Bile fistulas are rare, but can be life-threatening when associated with pancreatic fistulas. Because the only independent risk factor is the diameter of the RV, surgical technique is crucial. Regardless of existing classification systems, further studies should assess the adequate burden of hepaticoyanastomotic failure when combined with pancreatic fistula. Hepaticojejunostomy and combined complications after pancreatoduodenectomy are less common than pancreatic fistulas.

Prevention of early biliary complications is a difficult task. We noticed that the GEA stricture was facilitated by the use of 6/0 caliber sutures, which may be due to ischemia secondary to excessive sutures when using smaller caliber sutures.

Explaining that 50% of bile ducts resolve spontaneously while maintaining intra-abdominal drainage. In this case, mortality due to leakage of the biliary tract was zero. Minimally invasive methods are also effective.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P122—Effects of Antecolic Versus Retrocolic Reconstruction for Gastro/Duodenojejunostomy on Delayed Gastric Emptying After Pancreatoduodenectomy

S. Motelchuk¹, Volodymyr Kopchak ², O. Lytvyn¹, O. Duvalko¹, L. Pererva³, S. Andronik¹, P. Azadov¹

¹Shalimov National Institute of Surgery and Transplantology, Department of Pancreatic and Bile Ducts Surgery, Ukraine, ²Shalimov National Institute of Surgery and Transplantology, Head of the Department of Pancreatic and Bile Ducts Surgery, Ukraine, ³Shalimov National Institute of Surgery and Transplantology, Scientific researcher of the Department of Pancreatic Surgery and Bile Ducts Surgery, Ukraine

Purpose: To evaluate the influence of known methods of forming digestive anastomoses on the occurrence of delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD).

Materials and Methods: Postoperative complications occurred in 43 (42%) after PD (Table 1). Pancreaticoduodenectomy was performed in 102 patients according to standard methods: 50 (49%) patients underwent pyloric-preserving pancreaticoduodenectomy (PPPD), of which 13 (50%) were diagnosed with DGE, 52 (50%) patients underwent by the method of Whipple, of whom 10 (38%) were diagnosed with DGE

Results: Pancreaticoduodenectomy was performed in 102 patients. PPPD with antecolic manual duodenojejunostomy in 50 (49%) patients; PD with antecolic manual gastrojejunostomy in 48 (47%), with retrocolic manual gastrojejunostomy in 4 (4%). The average time of PPPD is 390—(230-600) minutes, PD—406 (255-760) minutes. The volume of intraoperative blood loss in PPPD was 367 (200-600) ml, PD—436 (200-1200) ml. The time of postoperative stay of the patient in the hospital is 30 (15-80) days after PPPD and 24 (6-42) days after pancreaticoduodenectomy without pylorus preservation. Slowing of delayed gastric emptying was diagnosed in 26 (25,5%).

Conclusions: Preservation of the pylorus during pancreaticoduodenectomy contributes to a higher level of slowing of gastric emptying than during resection of the pylorus. Duodenojejunostomy formed using stapled in pylorus-preserving pancreaticoduodenectomy given the small sample size of patients, it is difficult to assess the effect on the rate of slowing of gastric emptying in retrocolic or antecolic digestive anastomosis, and stapled anastomosis versus hand-sewn anastomosis. Further development and evaluation of methodologies are needed.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P123—Endoscopic and Laparoscopic Operations in the Treatment of Patients with Pancreatic Cysts

Yurii Grubnik ¹ , V. Fomenko¹, O. Yuzvak¹, M. Grubnik¹

¹Odesa National Medical University, Surgery Department №3, Ukraine

Aim: Reducing mortality and postoperative complications by performing endoscopic and laparoscopic operations.

Methods and materials: Over the past 3 years, we operated endoscopically 18 patients with pancreatic cysts. All patients underwent CT and ultrasound endoscopic examinations. In 10 cases were found cysts of the tail of the pancreas close to stomach. Patients was performed video endoscopic surgery—gastrocystostomy, with the introduction of a tubular drainage into the lumen of the cyst. In 5 cases, the cyst was located in the area of the pancreas body. In 3 cases, the cyst was located in the area of the pancreatic head, which required duodenocystostomy. Biopsy was performed in all patients with pancreatic cysts, followed by histological examination.

Results: Out of 18 patients, in 2 cases postoperative bleeding was observed, which required repeated endoscopy and local endoscopic hemostasis of the bleeding area, which in 1 case was ineffective and required a laparoscopic gastrotomy with coagulation and suturing of the bleeding area, followed by suturing of the stomach. In 1 case, cystoadenocarcinoma of the pancreatic tail cyst was detected. A laparoscopic pancreatic tail resection was performed. There were no lethal cases.

Conclusions: Endoscopic internal drainage of pancreatic cysts is an effective operation and it shortens the period of hospitalization of patients.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P124—Minimally invasive versus classical pancreaticoduodenectomy: our preliminary results

Tatiana Marques ¹, D. Melo Pinto¹, P. Valente, M.J. Costa², R. Peixoto, L. Barbosa, P. Moreira, E. Guerreiro, G. Faria

¹Unidade Local de Saúde de Matosinhos; Hospital Pedro Hispano, General Surgery, Portugal, ²Centro Hospitalar Tâmega e Sousa, General Surgery, Portugal

Aims: Pancreaticoduodenectomy is one of the most complex surgical procedures currently performed. Despite becoming increasingly safer in the last decades, its morbidity remains high. Regardless of minimally invasive surgery being the standard of care in many areas, considering pancreaticoduodenectomy (PD), the classical approach is still what prevails. Here we present our preliminary results comparing open and laparoscopic approaches for PD.

Methods: We collected data from the electronic medical record of all patients that underwent PD in our centre between January 2015 and December 2021. Statistical analysis was made using IBM SPSS and for all tests a p-value < 0,05 was considered statistically significant. A retrospective analysis was made including patients` clinical characteristics and comparing open and laparoscopic PD`s short term outcomes.

Results: A total of 66 patients, mean age of 70 years old, were included in the study, 29 of which had minimally invasive surgery (44%). Laparoscopic conversion rate was 24,1% (7/29). The median length of surgery was 6 h in the open surgery group and 8 h in the laparoscopic group (p < 0,05). Median blood loss was 400 mL in the open group versus 700 mL in the laparoscopic (p = 0,07), mainly due to surgeries needing conversion. Total laparoscopic PD`s median blood loss was 400 mL. C grade pancreatic fistula rates weren`t different between groups (13% open vs 10% laparoscopic), neither were the reoperation rate (p = 0,239), nor the median length of stay (26 days for both approaches). 30-day mortality rate was 5,4% in the classical approach group versus 3,7% in the minimally invasive one.

Conclusion: Our early results show no differences in the safety of the laparoscopic procedure when compared to the open approach, as the median blood loss, C level pancreatic fistula, reoperation and 30-day mortality rates were not statistically different. Improving the learning curve in laparoscopic PD might significantly improve clinical outcomes.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P125—Early surgery VS Late Surgery for Chronic Pancreatitis

Iurii Mikheiev ¹, O. Shpylenko¹, O. Babii²

¹State Institution “Zaporizhia Medical Academy of Post-Graduate Education Ministry of Health of Ukraine”, Surgery and Minimally Invasive Technologies, Ukraine, ²State Institution “Institute of Gastroenterology of NAMS of Ukraine”, Department of the Digestive Organs, Ukraine

Background: During last nine years, several studies showed advantages of early surgery in chronic pancreatitis, in three years after symptoms onset. The aim of this study is to research whether there are advantages of early surgery or not, especially for pain relief.

Materials and Methods: Retrospective analysis of data of 147 patients from 2001 to 2020, which undergone surgery for chronic pancreatitis. Patients who suffered from chronic pancreatitis symptoms 3 years or more were included in the control group ("late surgery"), and patients who noted symptoms of chronic pancreatitis less than 3 years were included in the study group ("early surgery"). All patients completed the EORTC QLQ-30, SF-36 questionnaires, as well as the questionnaire developed by the study authors, via telephone or mail or during the visit.

Results: According to all scales of the SF 36 questionnaire, except for "Physical functioning", the group of "Early surgery" prevails over the group of "Late surgery". The “Early Surgery” group had the best average scores on all functional scales of the EORTC QLQ-30 questionnaire compared to the Late Surgery group, except for the Cognitive Functioning scale. From the symptomatic scales, the Early Surgery group had the best averages of Pain and Diarrhoea. The average Health/Quality of Life scale was significantly better in the “Early Surgery” group.

Conclusion: The quality of life, pain, pancreatic function of patients operated on up to 3 years from the onset of symptoms of CP, compared with patients with longer disease duration, were better, with the same short-term results. The term of the disease is a major factor of the success of surgical treatment of chronic pancreatitis in terms of long-term results. The early surgery is effective approach to obtain better long-term outcomes in chronic pancreatitis.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P126—Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation

Ward van Bodegraven ¹ , M. De Pastena², T. Mungroop¹, F.L. Vissers¹, L.R. Jones³, G. Marchegiani², A. Balduzzi², S. Klompmaker¹, S. Paiella², G. Malleo², B. Groot Koerkamp⁴, C.H.J. van Eijck⁴, O.R.C. Busch¹, M. Luyer⁵, A. Alseidi⁶, R. Salvia², E.W. Steyerberg⁷, M. Abu Hilal⁸, C. Vollmer⁹, M.G. Besselink¹, C. Bassi²

¹Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands, Surgery, The Netherlands, ²General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy, Surgery, Italy, ³Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy, Surgery, Italy, ⁴Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands, Surgery, The Netherlands, ⁵Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands, Surgery, The Netherlands, ⁶Department of Surgery, Virginia Mason Medical Center, Seattle, United States, Surgery, USA, ⁷Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands, Biomedical Data Sciences, The Netherlands, ⁸Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy, Surgery, Italy, ⁹Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA, Surgery, USA

Introduction: Preoperative estimation of the risk of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) can be used for the selection of preventive strategies, for benchmarking across centers, and stratifying patients by baseline risk in clinical studies. The aim was to develop and externally validate the first clinical risk score for POPF after DP.

Method: Predictive variables for POPF were found using data of patients undergoing DP in two Italian centers (2014-2016) utilizing multivariable logistic regression. A prediction model was designed based on the significant variables. These data were pooled with the data of three Dutch centers and in two US centers (2007-2016). Discrimination and calibration were assessed in an internal-external validation procedure.

Results: Overall, 1336 patients were included, of whom 291 (22%) developed a POPF grade B/C. A preoperative risk score was developed, including two variables: pancreatic neck thickness (OR: 1.14 [95% CI:1.11-1.17] per mm increase) and pancreatic duct diameter (OR: 1.46; [95%CI: 1.32-1.65] per mm increase). The model performed well in the design cohort (AUC: 0.80 (95% CI: 0.76-0.84)) and after internal-external validation (AUC: 0.73 (95% CI: 0.70-0.76)). Three risk groups were identified: low-risk (0-10%), intermediate-risk (10-25%), and high-risk (> 25%).

Conclusions: The Distal Fistula Risk Score (D-FRS) is the first externally validated risk score that successfully predicts the risk of POPF after distal pancreatectomy. It can be easily calculated preoperatively using www.pancreascalculator.com. The three distinct risk groups may facilitate personalized treatment.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P127—Minimally-Invasive Pancreatic Enucleation (MI-pEn): Systematic Review and Metanalysis of short-term outcomes.

Raffaello Roesel ¹ , A. Cristaudi¹, L. Bernardi¹, S. G. Popeskou¹, P. E. Majno¹

¹EOC Regional Hospital of Lugano, General Surgery, Switzerland

Background: Minimally Invasive Pancreatic Enucleation, either laparoscopic or robot-assisted, is rarely performed. The aim of this study was to evaluate the published evidence for its short-term outcomes.

Methods: PubMed (MEDLINE), Cochrane Library and Scopus (ELSEVIER) databases were searched for articles published from January 1990 to August 2021. Studies which included more than 10 cases of minimally-invasive pancreatic enucleation were included. Data on the outcomes were synthetized and meta-analyzed when appropriate.

Results: Thirty-one studies involving 1740 patients were included in the systematic review, 799 patients (45.9%) underwent pancreatic enucleation with minimally invasive approach with 10% conversion rate. Minimally Invasive Surgery was performed in 63.5% of cases on the body/tail of the gland with a cumulative postoperative mortality of 0.13% and a major postoperative morbidity (Clavien-Dindo III-IV-V) of 50.3%. Clinically relevant pancreatic fistula was observed in 17% of the patients.

Eight studies with a total of 626 patients were included in the metanalysis. Compared with the standard open approach, mean length of hospital stay was significantly reduced in patients undergoing minimally invasive pancreatic enucleation of 2.32 days (95% CI: -3.80/-0.96; p = 0.001; I2 = 50%). Operative time, blood loss, major post-operative morbidity and clinically relevant pancreatic fistula rate were comparable between the two groups. One hundred and fourteen robot-assisted enucleations (performed in 54% of cases on pancreatic head/uncus), entered in a subgroup analysis with comparable results to open surgery.

Conclusion: Minimally-Invasive approach for pancreatic enucleation is feasible and reduces time to functional recovery compared with open surgery without increasing the risk of major complications, particularly clinically relevant pancreatic fistulas.

HERNIA-ADHESIONS—Abdominal Wall Hernia

P128—First Case Report of Abnormal Appendix in Recurrent Inguinal hernia in 74 Year Old Female Patient

S. Zino¹, Rahee Mapara ¹, R. Mapara¹, M. Ellslabi¹, J. Wilson²

¹Ninewells Hospital, General Surgery, United Kingdom, ²Ninewells Hospital, Pathology, United Kingdom

Background: Inguinal hernias are relatively rare in women, with a lifetime incidence of approximately 3% in females. Amyand hernias account for approximately 1% of inguinal hernias, where the appendix is found to be incarcerated within the inguinal hernia sac. The presence of appendicitis in recurrent inguinal hernia is extremely rare, only one case in a male patient has been reported in literature 2012.

Aims: we report the first case of abnormal appendix in recurrent inguinal hernia in 74 y female patient,

A 74 year old fit and healthy woman presented with an ongoing history of intermittent pain in the right iliac fossa. She had a CT scan demonstrated a right sided inguinal hernia containing a mildly thickened appendix and part of the terminal ileum. The patient had a history of bilateral inguinal hernia repairs more than 20 years ago. An open inguinal hernia repair was undertaken. Multiple small defects in the old repair were observed, but the main defect had a narrow neck and contained the appendix that was congested with a tight fibrinous band around the neck. Another defect contained a knuckle of healthy small bowel. Old stitches were removed, and transversalis fascia opened to get access to all defect simultaneously. A standard appendicectomy was performed. A further defect was noted within the conjoint tendon, superior to the internal ring, containing 6 cm × 1 cm projection of extra peritoneal fat that was resected and defect repaired with a Vicryl suture. The transversalis fascia was refashioned and the posterior wall was repaired with Vicryl 1 continuous in two layers then a standard Lichtenstein mesh repair was performed. The patient made a good recovery and was discharged home the following day. The pathology showed fat necrosis with associated calcification and macrophage in mesoappendix.

Conclusion: In this abstract we present the first case in literature of abnormal appendix in recurrent inguinal hernia.

HERNIA-ADHESIONS—Abdominal wall hernia

P130—Minimally Invasive Repair in Severe Rectus Diastasis with Midline Hernia Associated in Males Shows High Recurrence in Mid-term Follow-Up. Case–Control Study

Juan Bellido-Luque ¹ , E. Licardie¹, J. C. Gomez Rosado¹, A. Bellido-luque¹, I. sanchez-Matamoros¹, A. Nogales-Muñoz¹, J, Gomez Menchero¹, J. M. Suarez Grau¹, S. Morales-Conde¹

¹Virgen Macarena Hospital, Surgical Department, Spain

Introduction: An inter-rectus distance (IRD) more than 5 cm is labelled as severe diastasis. Endoscopic plication could develop excessive midline tension that could increase recurrence rate in patients with severe rectus diastasis (SRD) in midterm follow-up. Previously published minimally invasive endoscopic repair (FESSA technique)(FT) was proposed in those patients to corrects both pathologies decreasing the excessive midline tension. The present study aimed to assess clinical results, in terms of postoperative pain, functional recovery and recurrence rates of FT compared to endoscopic anterior rectus sheaths plication and mesh (ARSP), for ventral or incisional hernias and SRD associated. Secondary aims of the study were to identify intra- and postoperative complications associated with each technique.

Patients and methods: study design and population: All male patients with midline ventral or incisional hernia and SRD were included in a prospectively maintained databased and retrospectively analyzed from January 2017 to December 2020. Patients were collected from Quiron Sagrado Corazón Hospital in Seville, Spain. The distribution of FT of ST approaches were studied and grouped according to different time. From January 2017 to January 2019, patients with SRD and midline ventral or incisional hernias underwent to ARSP (Control group). From January 2019 to December 2020 patients with SRD and midline ventral or incisional hernias underwent to FT (Case group). The outcomes of patients who underwent ASRP were compared with those of patients who had SRD and midline hernias repairs using FT.

Inclusion criteria:

• Patients aged between 18 and 80 years old.

• Symptomatic midline ventral/incisional hernias with IRD > 5 cm.

For each patient, retrospectively, the following data were collected:

• Demographic: Age, Body mass index (BMI) risk factor for hernia recurrence and hernia type. Defect and diastasis width and length were measured using preoperative CT scan at rest.

• Surgical results:

O Operation time (minutes).

O Intraoperative complications.

O Hospital stay (days)

O Postoperative complications.

O Pain (VAS) preoperative and on 1th/7th/30th days using Eurahs Quality of life score for pain

O Functional recovery (Eurahs Quality of life score for restriction)

O Hernia recurrence: Clinical examination after 6 months and 1 year, as well as through an abdominal CT scan 6 month and 1 year after surgery.

Statistic

variables were compared using nonparametric tests. Chi-square test was used to evaluate categorical data. p values of < 0,05 were considered statistically significant. Data were expressed as mean ± standard deviation (SD)

Results: 55 male patients were eligible. 2 patients were lost during the follow-up. 53 patients were finally included. 28 patients underwent FT and 25 to ARSP. Mean defect width and length were 4 ± 1 cm and 3 ± 1 cm in FT group and 3 ± 1 and 3 ± 1 cm respectively in ARSP group. Mean diastasis width was 6 ± 1 in FT group and 5 ± 1 in APRS group, without significant differences.

No intraoperative complications were identified.

Mean operative time was 70 ± 9 min in FT group and 55 ± 7 min in ARSP group with significant differences.(p:0.00002)

Hospital stay was 1.4 ± 0,5 days for FT and 2,08 ± 0,5 days firo ARSP groups with significant differences in favor of FT group (p:0.00006)

Postoperative complications:

One postoperative suprapubic subcutaneous hematoma, requiring surgical removal (2%) in ARSP group and none in FT group..

Mean Pain at postoperative day 1 was 21 + /2 in FT group and 25 ± 2 in ARSP group without significant differences. When postoperative pain after 7 and 30 days were compared, significant improvement were shown in favor of FT (p < 0,05). Mean functional recovery at 1 postoperative month was 17,8 ± 2,4 in FT group and 27,8 ± 3,3 in ARSP group with significant improvement in favor of FT. After 6 months no differences were shown.

Overall recurrence after 24 months follow-up was 10 patient (28,9%).1 patient in FT group (3.6%) and 9 patient in ARSP group (36.0%) with significant differences in favor of FT (p = 0.004), ODDS RATIO: 0.06 in favor of FT.

Conclusions: Minimally invasive endoscopic Anterior rectus sheaths plication with mesh in severe rectus diastasis and midline hernias, shows higher recurrence rate, postoperative pain and worse functional recovery due to probably excessive midline tension. New endoscopic technique bringing together the medial aspects of both anterior rectus sheaths after those have been incised, solve the higher midline tension, minimizing the risk of recurrences and improving the postoperative pain and functional recovery.

HERNIA-ADHESIONS—Abdominal wall hernia

P131—Role of Transversus Abdominis Plane (TAP) Block in Analgesia and Early Rehabilitation in Patients with Inguinal Hernias

Zhanna Ushnevych ¹, N.V. Matolinets², O.M. Lerchuk³, V.V. Khomyak⁴

¹Lviv Regional Clinical Hospital, Anesthesiology, Ukraine, ²Danylo Halytsky Lviv National Medical University, Anesthesiology, Ukraine, ³Lviv Regional Clinical Hospital, Surgery, Ukraine, ⁴Danylo Halytsky Lviv National Medical University, Syrgery, Ukraine

Aim: To evaluate the efficiency and role of TAP block in analgesia and early rehabilitation in patients with inguinal hernias.

Methods: The study included 56 patients who underwent laparoscopic transabdominal preperitoneal hernioplasty for inguinal hernias during 2020 in the surgical department of Lviv Regional Clinical Hospital. The mean age of patients was 63.2 ± 12.2 years. We applied the principles of ERAS protocols in every case. All patients underwent general inhalation anesthesia with sevoflurane. Intraoperatively, fentanyl was administered at a dose of 100 μg before tracheal intubation, then, if necessary. Patients were divided into 2 groups: group I (n = 32) we used intravenous multimodal non-opioid analgesia after surgery; in group II (n = 24) after tracheal intubation, a TAP block was performed under ultrasound control with bupivacaine and lidocaine combination. After surgery, if necessary, intravenous dexketoprofen was administered. There were no significant statistical difference in both groups in age, body weight and hernia size. Anesthetic risk in patients of both groups was assessed as ASA II-III.

Results: Intraoperatively, the need for fentanyl in group I was 280 ± 54 mcg, in group II 120 ± 40 mcg. The average intensity of pain for visual analog scale for the first day after surgery was 2.5 ± 0.5 points in group I, 1.2 ± 0.4 points in group II. Only 3 patients (12.5%) from group II required additional single administration of dexketoprofen in the first day after surgery. There was no need for opioids in the postoperative period in either patient in either group. In group I, postoperative nausea occurred in 4 patients (12.5%) and vomiting in one patient (3.1%). In group II, no patients had episodes of postoperative nausea and vomiting. Group I patients were able to verticalize and walk an average of 12 h after surgery, this interval in group II was—6 h. The first full meal in group I took place on average 7 h after surgery, and in group II—4 h after surgery.

Conclusions: TAP block significantly improves the quality of analgesia, reduces the intraoperative need for opioids and accelerates the rehabilitation of patients.

HERNIA-ADHESIONS—Abdominal Wall Hernia

P132—Slim-Mesh: 12-Year Follow-Up Study on Mid-Term Results in 120 Patients Including 58 Obese

Silvio Alen Canton ¹ , C. Pasquali¹

¹University of Padova, Department of Surgery, Oncology and Gastroenterology, Italy

Aims: Using the sutureless “Slim-Mesh” technique (SM) to render the best therapeutic treatment plan for patients with ventral hernia (VH), including large (L)-giant (G)/massive (M) types and obese/super obese patients (O/SO), likely resulting in decreased operation time (OT) and intra- (IO)/post-operative (PO) complications, as well as decreased postoperative chronic abdominal-wall pain (CAP) and recurrence (R).

Methods: From September 2009 to October 2021, 120 VH patients, including many O (BMI 30-49.9 kg/m2)/SO (BMI 50-59.9 kg/m2) patients, 43 of which with L (10-14.9 cm in diameter for circular or major axis for oval ones)-G (15-19.9 cm) and M (≥ 20 cm) VH, were treated with the SM technique at our Department. This was a prospective (72%)-retrospective 12-year follow-up study to analyze the mid-term results (m.t.).

Results: Our study comprised 59 males and 61 females, with overall mean age and BMI being 59 years old and 29 kg/m²respectively. Fifty-seven (48%) patients were O and one was SO. Laparoscopy (LAP) found 77 small (S 2-4.9 cm)-medium (Me 5-9.9 cm) VH, 37 L-G, and 6 M. Mean OT was 98 min for all 120 patients, 88 min. for S-Me VH patients, 104 min. for L-G, and 190 min. for M. In 27% of cases, VH LAP size was larger than pre-operative size, and in 14%, LAP detected additional-VH undetected by US and/or CT-scan. A composite mesh and a non-composite mesh were employed in 93% and 7% of cases respectively. Absorbable straps and titanium-tacks were used in 88% and 12% of cases respectively. Mean hospital-stay was 2.3 days and mean follow-up time was 4 years. There was one case of CAP, and 12 late PO complications: 7 VH recurrences (6%) and 5 trocar-site hernias.

Conclusions: There is no consensus of literature on the optimal therapeutic treatment for patients with L-G/M VH and O/SO VH patients; however, our study confirms that the SM technique significantly helps to reduce OT and IO/PO complications, even when treating these two categories. In our experience, the SM technique is justified for VH patients, especially those with L-G/M VH, as well as for O/SO VH patients, thus strengthening the role of LAP.

HERNIA-ADHESIONS—Adhesions

P133—Laparoscopic Versus Open Adhesiolysis in Patients with Small Bowel Obstruction: A Single-Center Retrospective Study

Y. Lovitskyi¹, Inesa Huivaniuk ¹ , I. Huivaniuk¹

¹Medical and Diagnostic Center "Dobrobut", Surgery Department, Ukraine

Background: Laparoscopic adhesiolysis is an alternative for open surgery in an adhesive small bowel obstruction. Despite a large amount of retrospective and prospective studies, there is still a gap in understanding of how it works in a private hospital in Ukraine.

Methods: We analyzed the prospective database to determine the immediate surgical outcomes of the 52 patients, operated because of adhesive small-bowel obstruction in a private hospital in Kyiv, Ukraine, between January 2019 and May 2021. The main objects were to evaluate 30 days postoperative morbidity, mortality and readmission rates, length of hospital stay, pain control, operative time.

Results: A total of 23 patients underwent laparoscopic adhesiolysis and 29 patients had surgeries performed by open approach. Laparoscopic group of patients was accurately selected: younger, had fewer previous abdominal operations, and by enhanced computed tomography of abdomen less adhesions were suggested. The mean operative time for laparoscopic procedures was substantially less than for open (56,80 ± 25,02 min vs. 134,69 ± 67,51 min). Postoperative hospital stay (4,00 ± 1,21 days vs. 7,13 ± 3,33 days, p = 0.041) was found to be shorter in laparoscopic group. Patients after laparoscopic procedure experienced significantly less pain on the 1st postoperative day (mean VAS-score was 2.4 vs 6.1). Severe complications` rate (Clavien-Dindo 3A or higher) was 0% in the laparoscopic group versus 13.79% in the open approach group. There were not readmissions found in any of groups. There was no death in both groups during the 30 days follow up.

Conclusions: In highly selected patients laparoscopic approach for management of adhesive small-bowel obstruction appeared to be safe and feasible.

HERNIA-ADHESIONS—Adhesions

P134—A Pilot on Virtual Reality in Management of Adhesion-related Chronic Abdominal Pain

Masja Toneman ¹ , H. van Goor¹, R. ten Broek¹

¹Radboudumc, Surgery, The Netherlands

Aim: Chronic pain affects quality of life in 10- 20% of patients following abdominal surgery. Adhesion formation is the most common cause of chronic postoperative abdominal pain. Although surgical release of adhesions is effective in selected patients, many patients depend on conservative treatments. The aim of this pilot study is to assess feasibility, usability and efficacy of virtual reality (VR) in patients with chronic pain related to post-operative adhesions.

Methods: Patients with chronic abdominal pain related to adhesions diagnosed by CineMRI who are treated with VR therapy (Reducept and relaxation modules) at home during 4 weeks are included in this observational pilot study. Questionnaires at baseline, 4 weeks (ending of therapy period) and 12 weeks were taken. Questionnaires include Pain Disability Index (PDI), Patient Health Questionnaire (PHQ-9) and DETECT questionnaire. User experiences are evaluated through semi-structured interviews.

Results: Eleven patients with chronic pain related to adhesions are included in this pilot, of which 9 women (81%) with a mean age of 51 (range 39-74). In 8 patient the DETECT score was positive, indicating pain with neuropathic component. The user experience was positive in 6 patients (55%), neutral in 4 (36%) and negative in 1 patient (9%) due to side effects. Overall, side effects—vertigo or nausea—occurred in 2 patients (18%), all short term and self-limiting. The average pain numeric rating scale (NRS) score was 6.5 at baseline and 5.9 after the 4-week treatment period. PHQ-9 scores at baseline were on average 15.4 (indicating moderate severe depression) and lowered to 11.9 after 4 weeks of VR usage (indicating moderate depression). PDI at baseline was 6.5 on average and 5.8 after 4 weeks. During the treatment period 4 patients (36%) experienced technical difficulties with the Reducept module, the goggles did not cause problems.

Conclusion: Based on this pilot, VR seems feasible and usable for patients with chronic abdominal pain after abdominal surgery. In this small cohort, a trend towards reduction of pain experience, influence of pain on daily activity and positive effect on mental health is shown. However, extensive research is necessary to determine the efficacy in a larger cohort.

HERNIA-ADHESIONS—Emergency surgery

P135—Laparoscopic Management of Early Dislodgment of Percutaneous Endoscopic Gastrostomy Tube: A Case Report

Y. Lovitskyi¹, Inesa Huivaniuk ¹ , I. Huivaniuk¹

¹Medical and Diagnostic Center "Dobrobut", Surgery Department, Ukraine

Background: Percutaneous endoscopic gastrostomy (PEG) tube placement is a preferred method of providing enteral nutritional support for patients who need it for three weeks and more, but can not take food per os. Early PEG dislodgement between postoperative day 0 and 7 occurs in < 5% of cases and usually demands an emergent surgery by open approach.

Case presentation: A 48-years old male presented to emergency department with 6-h history of worsening abdominal pain. 36 h ago this patient with tongue cancer and subsequent dysphagia underwent PEG. Symptoms appeared after food had been induced into the tube. After gastrografin was injected in the PEG tube, abdominal computed tomography scans showed free air, fluid, extravasation of contrast, and migrated tube in the peritoneal cavity. Laparoscopic exploration confirmed gastrostomy tube dislodgment with diffuse secondary peritonitis. Abdominal cavity was irrigated, PEG tube was removed and a true Stamm gastrostomy was performed laparoscopically. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day.

Conclusions: PEG dislodgement is rare, but easily diagnosed complication, which leads to secondary peritonitis and traditionally requires emergent open surgery. Early recognition and management of this state is crucial. Peritoneal cavity irrigation with gastrostomy tube replacement is a standard of care. Laparoscopic approach is safe and effective option if a recognition of PEG dislodgement is early.

HERNIA-ADHESIONS—Emergency Surgery

P136—Laparoscopic Management of Mesenteric Inflammatory Myofibroblastic Tumor Torsion: A Case Report

Y. Lovitskyi¹, Inesa Huivaniuk ¹ , I. Huivaniuk¹

¹Medical and Diagnostic Center "Dobrobut", Surgery Department, Ukraine

Background: Inflammatory myofibroblastic tumors (IMTs), also known as inflammatory pseudotumors are rare type of mesenchymal tumors with malignant potential, the most frequently involved sites are mesentery and omentum. Mesenteric IMTs are usually asymptomatic, but can also cause acute abdominal pain and sometimes need emergency surgery. A review of the literature shows that only a relatively small number of mesenteric IMTs complications have been reported.

Case presentation: A 29-year-old female was hospitalized due to fever, localized muscle tenderness and right upper quadrant abdominal pain. The patient mentioned that she has suffered from symptoms for 2 days and had one the same episode in the past. Laboratory studies showed elevated white blood cells count (WBC—13,2*109/L) and c- reactive protein level (CRP—120 mg/L). An abdominal computed tomography (CT) scan was performed, and 7-cm heterogeneous mesenteric mass lesion was found at right upper quadrant. The patient underwent laparoscopic exploration. During operation, was found pedunculated tumor at the mesentery of proximal jejunum, 7 cm × 7 cm × 4 cm in size, with torsion of the pedicle and local inflammatory reaction. The lesion was excised without the need for bowel resection. The postoperative course was uneventful. The patient was discharged 2nd postoperative day. On histopathological examination neoplasia was diagnosed as IMT.

Conclusions: Mesenteric IMT can become symptomatic and present as an acute condition. We present the rare diagnosis of IMT, which may present as a mimic of other pathologies resulting in acute abdominal pain. Identification and recognition can assist clinicians to plan for its resection and the operative approach required to achieve this. Exploratory laparoscopy is a preferred method to confirm diagnosis. In some cases laparoscopic approach also may be safe and effective treatment modality.

HERNIA-ADHESIONS—Emergency surgery

P138—Laparoscopic Management of Perforated Meckel’s Diverticulum: A Case Report

Inesa Huivaniuk ¹ , Y. Lovitskyi¹

¹Medical and Diagnostic Center "Dobrobut", Surgery Department, Ukraine

Background: Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, caused by incomplete obliteration of the vitelline duct. The incidence of this true diverticulum of the small intestine is 2% of general population, the risk of complications is 4 to 6%.

Case presentation: We report a case of 52-years old man, who presented to emergency department with 2-days history of right-sided abdominal pain, localized muscle guarding and fever. Contrast enhanced computed tomography of abdomen revealed a perforated Meckel's diverticulum with the formation of intra-abdominal abscess, which was confirmed later during laparoscopic exploration. The abscess was drained and perforated Meckel’s diverticulum was identified approximately 80 cm proximal to ileocecal valve. Diverticulectomy was performed with endostapler. The postoperative course was uneventful and the patient was discharged on the 6th postoperative day.

Conclusions: Meckel’s diverticulum perforation is rare, but clinically significant serious complication. The diagnosis is often difficult because this condition can mimic other acute abdominal pathologies and early recognition must occur in order to provide the best outcome. Diverticulectomy is the standard of care and laparoscopic approach seems to be safe and effective modality.

HERNIA-ADHESIONS—Emergency surgery

P140—Diagnostic Hernioscopy to Check Intestinal Recovery in Urgent Surgery for Incarcerated Hernia

J. R. Gómez López¹, Jeancarlos Trujillo Díaz ¹ , J.J. Trujillo Díaz¹, C. Martínez Moreno¹, P. Concejo Cútoli¹, J. Atienza Herrero¹, J. C. Martín Del Olmo¹

¹Hospital de Medina del Campo, General Surgery, Spain

Aims: Inguino-crural hernia surgery is a frequent pathology in emergency surgery. Incarcerated inguinal hernia sometimes requires intestinal resection. This situation sometimes depends on the surgeon's experience. The aim of this work was to propose the performance of a low pressure laparoscopy, through the hernial orifice, to visualize the released intestinal loop and its correct recovery after its reintroduction into the abdominal cavity.

Methods: Most of our patients with incarcerated hernia have several pathologies, so urgent intervention is performed under spinal anesthesia. Since 2015, if during the intervention the intestinal loop was reintroduced without verifying its complete recovery or if there were doubts about it, a laparoscopy was performed through the hernial orifice, to verify the viability of the intestinal loop.

Results: In the last 6 years, 8 patients undergoing emergency surgery under spinal anesthesia due to incarcerated inguinal or femoral hernia were collected. A "hernioscopy" was performed through the hernial orifice sac, in order to identify the intestinal loop once it had been reduced. A 10 mm optical trocar was inserted with the video endoscope and CO2 was injected at a low pressure of 4-6 mmHg. Complete recovery of the intestinal loop was verified in all cases. The trocar and gas were removed. The hernial sac was closed and the hernia was repaired using low-density mesh according to standard techniques.

Conclusion(S): In our series it was possible to see the bowel loops of the 8 patients, allowing their adequate treatment, without complications and with an early discharge from hospital. If it had not been visualized, the patient would have been admitted for observation for an additional 24—48 h, or complementary studies such as analytics or imaging tests would have been performed. Hernioscopy is a resource available in any surgery service today, which can allow checking intestinal viability in a safe and non-aggressive way for patients.

HERNIA-ADHESIONS—Emergency Surgery

P141—Staged Management of a Case of Traumatic Total Avulsion of the Anterior Abdominal Wall: A Rare Case Report

Karim Ibrahim Fahmy ¹ , M. Ahmed¹, M. Salama¹, A. Bessa¹

¹Damanhour National Medical Institute, General Surgery, Egypt

Objective: Analyzing the stages of surgical management of a patient who sustained a traumatic anterior abdominal wall total avulsion with evisceration of all the abdominal organs.

Background: Significant anterior wall injuries are extremely rare, carrying an estimated prevalence of 0.2-1%. Hence, we are citing this case in which a patient presented with total avulsion of the anterior abdominal wall, with complete evisceration of all the abdominal viscera as well as massive tissue loss, extending from the level of the hypochondrium to the anterior superior iliac spine on both sides. According to the acknowledged grading system of abdominal wall injury, the case was regarded as grade VI (loss of skin, subcutaneous tissues, fascia, and muscles).

Overview: A 39-year-old male patient was brought to our emergency department after he sustained a worksite injury. Upon examination, the patient was shocked with unrecorded blood pressure and total exposure of all abdominal organs. He was resuscitated with pRBCs and plasma and was taken to OR for emergency abdominal exploration. After toilet washes, exploration revealed multiple segments of ischemic bowel loops. Damage control was decided, with resection and ligation of the ischemic segments on two levels; the most proximal was 20 cm from the duodenojejunal junction. At the level of the jejunum, an enterotomy was done with a Foley catheter fixed to the chest wall, and the abdomen was covered with sterile towels. Two days later, a second look took place, in which the edges of the resection sites were trimmed, with secondary anastomoses: side-to-side 70 cm from the DJ junction and end-to-end 1.5 m from the ileocecal valve. Moreover, jejunostomy was done for feeding, and the abdomen was covered by a vicryl mesh to support the abdominal organs and allow the growth of healthy granulation tissues.

Discussion: Significant abdominal wall injuries are very rare, with only a few publications citing the management of such cases. We are offering our case for open discussion about the best techniques and guidelines to follow upon dealing with such cases.

HERNIA-ADHESIONS—Emergency Surgery

P142—Endovideosurgical Technology in the Treatment of Perforated Gastroduodenal Ulcers

Aleksandr Ukhanov ¹ , D. Zakharov¹, S. Zhilin¹, S. Bolshakov¹, A. Leonov¹, K. Muminov¹, J. Aselderov¹

¹Central Municipal Clinical Hospital, Surgical, Russia

The Aim: Improving of the results of operative treatment of the patients with perforated gastroduodenal ulcers due to expansion of indication for endovideosurgical technology.

Material and Methods: 416 patients with perforated ulcers of stomach and duodenum were operated on from 2013 till 2021 years. Age of the patients varied from 18 till 78 years. Laparoscopic treatment with Z-suturing of perforated hole and bubble test was carried out in 152 cases (36,5%). 264 patients were operated on by laparotomy.

Results: Conversion rate was 3,3% (5 from 152 cases). One patient was operated on again a few hours after initial operation due to duodenal sutures leakage. Relaparoscopy and additional suturing was carried out with good result. Postoperative morbidity was 5,3% (8 cases). One patient after laparoscopic treatment died (0,7%), while in the group with open treatment of perforated ulcer postoperative mortality was 7,2% (19 patients from 264 died).

Conclusion: Expansion of indication for endovideosurgical technology has definite advantages over open methods in the surgical treatment of perforated gastroduodenal ulcer and, in the absence of contraindication should more widely applied in the urgent surgery departments.

Keywords: Peptic ulcer, Perforation, Laparoscopic suturing

HERNIA-ADHESIONS—Emergency surgery

P143—The Use of Minimally Invasive Technologies in the Treatment of Acute Surgical Diseases of the Abdominal Cavity

Aleksandr Ukhanov ¹ , D. Zakharov¹, S. Zhilin¹, S. Bolshakov¹, K. Muminov¹, J. Aselderov¹,

¹Central Municipal Clinical Hospital, Surgical, Russia

Aim: to evaluate main trends and outcomes of emergency surgical care among patients with acute surgical diseases of the abdominal cavity admitted to the Central City Clinical Hospital, Velikiy Novgorod, during 2011-2021.

Material and Methods: During study period between 2011 and 2021, 12,535 patients with acute surgical diseases of the abdominal cavity were admitted to the Central City Clinical Hospital, 8,397 (67.0%) of those patients underwent surgical treatment. Among the operated patients, 5,237 (62.4%) underwent minimally invasive interventions using videolaparoscopy or puncture-drainage operations under ultrasound control. In 3,160 patients the surgical intervention was performed by laparotomy.

Results: In the treatment of acute appendicitis and acute cholecystitis, the share of laparoscopic interventions was 99 and 98%, respectively. There is an increasing trend in performing minimally invasive interventions for perforated gastric and duodenal ulcers, acute intestinal obstruction and acute pancreatitis treatment, where the rates of those procedures increased 5.9, 9.3 and 2.2 times, respectively, over the last five years.

Conclusion: Expansion of the use of minimally invasive technologies in medical institutions of the second level, which includes the Central City Clinical Hospital in Velikiy Novgorod, which is an interdistrict center, allows to provide modern surgical treatment to the residents of rural and remote communities, and thereby increases the availability of specialized surgical care throughout the region.

HERNIA-ADHESIONS—Emergency surgery

P144—Original Article Section: Surgery Comparative Study of Laparoscopic Versus Open Appendicectomy for Acute Appendicitis -A Prospective Study

Bhavesh Devkaran ¹

¹Royal Liverpool and Broadgreen University NHS Trust, General Surgery, Renal Transplant and Vascular Access, United Kingdom

Background: Acute appendicitis is the most common cause of an “acute abdomen” in young adults. Appendicectomy is the most common procedure performed in emergency surgery. There is lack of consensus for the most appropriate technique for appendicectomy. Laparoscopic appendicectomy has not become gold standard treatment for acute appendicitis unlike laparoscopic cholecystectomy for gallstone disease. The advantages of laparoscopic appendicectomy over open appendicectomy are questioned time and again. There have been many studies which concluded that laparoscopic appendicectomy is better as compared to open appendicectomy in patients of acute appendicitis in many aspects.

Objective: The primary objective of this study was to compare the outcomes of laparoscopic and the open approach in the treatment of acute appendicitis.

Methods: The study included 400 cases of appendicectomy, 200 open and 200 laparoscopic, which were randomly selected and were operated in the department of general surgery, Indira Gandhi Medical College Shimla. The following parameters were compared between the two groups: operative time, blood loss, intra-operative complications, analgesic requirement for first 48 h, time to start ambulation, time for the bowel sounds to recover, time to start clear liquids and regular diet, wound status, discharge from the hospital (post op day), postoperative complications, time taken for return to normal activity and cosmetic outcome. Chi-square test and student t-test were used for statistical analysis.

Results: Present study clearly proves that laparoscopic appendicectomy is better as compared to open appendicectomy in terms of post-operative pain, analgesic requirement, time to start ambulation, hospital stay, time to return to normal activity and cosmetic outcome. Laparoscopic appendicectomy was comparable to open appendicectomy in terms of operative time, time required for the bowel sounds to recover, time to start liquids and regular diet, wound infection and other complications in the present study.

Conclusion: Laparoscopic technique in appendicectomy is safe and it clearly provides advantages over the open technique.

HERNIA-ADHESIONS—Emergency Surgery

P145—The Impact of the COVID-19 Pandemic on Acute Surgical Care

Zsolt Simonka ¹ , J. Tajti¹, A. Lepran¹, K. Kovach¹, G. Lazar¹

¹University of Szeged, Department of Surgery, Hungary

Introduction: The coronavirus pandemic has fundamentally changed the healthcare system. At the highest peak in Hungary when restrictions were put into place for 146 days in which planned surgeries for benign diseases were also restricted. Our assumption was that this event affecting two fifths of the year of 2020 could lead to an increase in the number of emergency cases.

Patients and Method: We compared the surgical distribution in one year from before the pandemic (2019) and during the pandemic (2020) at the Department of Surgery, University of Szeged. The number of emergency appendectomies, cholecystectomies and hernias were analysed.

Results: In 2019, 212 appendectomies were performed whilst in 2020 it was 181. This represents a 15% reduction in expected appendectomies. In 2019, out of the 676 cholecystectomies, 52 were acute cases. Due to the restrictions in 2020, the number of cholecystectomies reduced to 422 surgeries, of which 40 were emergency cases. There was a 38% reduction in all cholecystectomy surgeries and the emergency surgical cases only showed a 23% decrease. In 2019, there were 536 hernia surgeries, of which 82 were emergency cases. In 2020, there was a decrease in the hernia surgeries to 429, of which 54 cases were acute cases. The hernia surgical cases decreased by 20% in the year of 2020. However, the number of emergency surgeries (incarcerated hernia cases) fell by 34%.

Conclusion: Contrary to our assumption, the number of appendectomies which represented a standard emergency surgical care decreased by almost the same proportion as the total number of surgeries. The number of planned cholecystectomies and hernia surgeries decreased by 39% and 17% respectively, but this did not lead to an increase in the number of emergency cholecystectomies and hernia surgeries, paradoxically the number of which also decreased. This can only be partially explained by the possibility of conservative treatment and the change in indication for surgery. Further investigations are needed to clarify other causes.

HERNIA-ADHESIONS—Emergency Surgery

P146—Pneumothorax Secondary to Nasogastric Tube Insertion—Case Series Report and Literature Review

Mohamed Salama ¹, M. Salama², W. Shabo³, I. Ahmed³

¹Our Lady of Lourdes Hospital, General Surgery, Ireland, ²Trinity College Dublin, School of Medicine, Ireland, ³Our Lady of Lourdes Hospital, Ireland

Introduction: Nasogastric tube (NGT) feeding has been around since it was first reported by John Hunter in 1769. Nowadays, it is extensively used worldwide, particularly for critically ill patients. Though it seems a simple procedure, it may carry potential life-threatening complications due to misplacement. Many practitioners may not have considered the real potential fatal complications. We report our case series to raise awareness of NGT potential complications and recommend some critical points to minimise these preventable complications.

Case 1: A 73 year old lady, admitted with COVID 19, type I respiratory failure. She has a background history of DM type 2, IHD, CCF, CVA, DVTx3, CKD 3b, hypothyroidism, hypertension, ?Renal Cell Carcinoma. She had tracheostomy placed and fine bore NGT was inserted, and complicated with right-sided pneumothorax. Chest drain was inserted subsequently and lung became fully expanded. The drain was removed after patient’s full recovery.

Case 2: An 89 year old lady, admitted with community acquired pneumonia, bilateral consolidation and pleural effusion. She had a fine bore NGT inserted, and complicated with right sided pneumothorax therefore a chest drain was inserted. Unfortunately patient passed away after few days.

Case 3: An 84 year old lady, admitted with septic shock, asthma exacerbation and hypoxia. Fine bore NGT was inserted, and complicated with right-sided pneumothorax therefore a chest drain was inserted. Unfortunately, patient passed away few days later.

Conclusions: Traditionally NGTs have been inserted blindly. Bedside confirmatory signs may not be reliable. Check x-ray detects the complication but does not prevent it. Pneumothorax is the most common complication of NG insertion. The 2-step insertion is an ideal way to prevent complications. Insertion of excess tubing is to be avoided. Tracheal entry can be detected using small disposable capnometers. Nasal endoscopes with guide-wire exchange are ideal for high-risk patients. Experienced operator, pre-NGT insertion risk assessment, proper technique of placement and post insertion confirmation are fundamental recommendations for safe NGT insertion

HERNIA-ADHESIONS—Emergency surgery

P147—Operating Room (OR) Utilization in Our Hospital—Can It Be Improved?

Mohamed Salamam ¹ , A. Gadura¹, M. Khalifa², B. Sami¹, I. Ahmed¹,

¹Our Lady of Lourdes Hospital, General Hospital, Ireland, ²NUI Galway, School of Medicine, Ireland

Introduction: Healthcare systems are facing a difficult period characterised by increasing costs and spending cuts due to economic problems. ORs are a costly component of the hospital budget expenditure. They require maximum utilisation to ensure optimum cost benefit. We intend to render the OR process efficient and safe. We focus on the OR due to an urgent need to deliver high quality care with limited resources. Delay in patients’ transportation to the OR is a globally recognised phenomenon leading to subsequent delays.

Aims: To evaluate reasons for delay in transporting patient to OR and how to eliminate them

Methods: Retrospective study of general surgical emergency cases collected over 6 weeks.

Data collected: Date, Time (normal working days, out of hours)

Arrival time: Time from calling the patient to OR arrival.

Anaesthetic time: Time between sign-in and skin incision.

Recovery time: Time spent in the recovery room.

If the arrival time is more than 30 min, the reasons for delay were recorded.

Results: Total number—101, Documentation not complete—34 (33.7%)

Average arrival time: 21.4 min, Average anaesthetic time: 21.1 min, Average recovery time: 56.3 min.

Recovery times: Daytime: 56.25 min, Night-time: 56.53 min, Weekends: 48.18 min

Laparoscopic appendectomy: 49.5 min, Laparoscopic Cholecystectomy: 72.5 min.

7 cases bypassed the recovery room directly to the ward.

5 patients had delayed transportation from the ward to the theatre of more than 40 min (1 patient in ED, 1 Paediatric patient needing pre-med, 1 checklist not signed, 1 porter not available, 1 anaesthetic machine fault).

During the study period, there were no theatre porters available between 20:00 and 21:00.

Conclusions: The time interval of OR time utilization for most general surgical emergency cases ranged within acceptable limits being comparable to the time estimates of published operating lists. The documentation in our theatre list was sub-optimal. Due to delayed transportation of some cases, special emphasis towards improvement of OR time should be paid. We believe there is room for improvement.

HERNIA-ADHESIONS—Emergency surgery

P148—Pathological Changes in the Abdominal Cavity in Acute Appendicitis in the Postcovid Period According to Laparoscopic Appendectomy

Vasyl Mishchenko ¹ , V.P. Mishchenko², I.V. Rudenko³, P.I. Pustovoit⁴, R.Y. Vododyuk¹, V.V. Velichko¹, I.P. Pustovoit⁵

¹The Odessa National Medical University, Department of Surgery 1, Ukraine, ²The Odessa National Medical University, Department of Obstetrics and Gynecology, Ukraine, ³Thumbay University Hospital, Gulf Medical University, United Arab Emirates, ⁴Odessa Regional Clinical Hospital, Head of the Department of Minimally Invasive Surgery, Ukraine, ⁵The Odessa National Medical University, Department of Urology and Nephrology, Ukraine

Purpose: determination of pathological changes in the abdominal cavity in patients with acute appendicitis in the postcoid period, detected during laparoscopic appendectomy.

Materials and Methods: Laparoscopic appendectomy was performed in 73 patients. The average age of the surveyed was 25.7 ± 0.5 years. The Alvarado scale was used for diagnosis. The presence of peritoneal symptoms was an unconditional indication for surgery. The Olympus OTV-SC endosurgical complex was used for laparoscopic appendectomy. Anesthesia—endotracheal anesthesia. The pressure of carbon dioxide in the abdominal cavity was maintained at the level of 10-12 mm. mercury column. The location of the troacars depended on the location of the appendix and was determined by the need to comply with the basic principle of triangulation. Appendectomy was performed using bipolar coagulation in standard modes of exposure, the stump of the appendix was processed with Reder's loops—a ligature method. The operation was completed with the installation of a safety drainage.

Results: In 12.3% of patients, the time from the onset of the disease was 6 h, in 35.6%—6-12 h, in 31.5%—12-24 h, in 20.5%—more than 24 h. The preoperative follow-up period was 5.4 ± 1.2 h. During the revision of the abdominal cavity, the visceral and parietal peritoneum in the right iliac region and the pelvic region, areas of the serous cover of the large and small intestines were with pronounced signs of edema, covered with a vesicular rash, in places in the conglomerates that were bleeding. There was no effusion in the abdominal cavity. The early and late postoperative periods proceeded without surgical complications. Disorders in the blood coagulation system, the immune system, positive definitions of IgG and IgM Covid-19 were revealed. All patients were discharged within 2 to 5 days after surgery. Conclusions. Appendectomy in patients who have undergone COVID-19 should be performed even before the development of complications from acute appendicitis. Laparoscopic appendectomy due to its advantages over open appendectomy, its safety should now become the gold standard for acute appendicitis surgery in patients with COVID-19.

HERNIA-ADHESIONS—Inguinal hernia

P149—Optimization of TAPP in Case of Recurrent Inguinal Hernias After Liechtenstein Surgery

Yaroslav Feleshtynsky ¹ , A. A. Shtayer¹, V. V. Smishchuk¹, S. A. Sviridovskyi¹

¹Shupyk National Healthcare University of Ukraine, Surgery and Proctology, Ukraine

The classic method of TAPP in case of recurrence of inguinal hernia after Liechtenstein surgery does not always ensure the reliability of the closure of the mesh implant hernia defect, accompanied by recurrence (5-10%).

The aim: Increase the effectiveness of TAPP in case of recurrence of inguinal hernia after Liechtenstein surgery.

Material and method. Surgical treatment of 68 patients with recurrent inguinal hernias after Liechtenstein surgery was performed using advanced and classical TAPP methods. Age of patients from 25 to 80 years, mean age 58 ± 1.3. All patients were male. Depending on the method of operation, patients were divided into two groups. In the first (main) group in 34 patients the operation was performed according to our improved TAPP, which consists in strengthening the inguinal area using a mesh implant 15 × 15 cm, larger than the classic with an overlap on the upper edge of the defect 4-5 cm and fixing with Liqui Band Fix 8 glue around the perimeter ulcer fixation on the lower edge of the defect. In the second group (comparison), 34 patients performed the classic TAPP technique using a ProTack herniostepler. Patient groups were comparable in age and size of recurrent inguinal hernias.

Results and discussion: In the postoperative period, chronic inguinal pain was observed in 3 (8.8%) patients of the comparison group. No chronic inguinal pain was observed in patients of the main group. Long-term results were studied by repeated examinations and ultrasound diagnostics for a period of 1 to 3 years. Recurrences of inguinal hernia were found in 4 (11.8%) patients of the comparison groups. The absence of recurrence among patients in the main group was achieved due to the wider coverage of the inguinal defect and fixation of the network with glue, especially in the lower parts, which eliminates nerve trauma and migration of the network.

Conclusion: Improved TAPP in recurrent inguinal hernia after Liechtenstein surgery using a larger mesh implant with adhesive fixation improves treatment outcomes compared to classical TAPP.

HERNIA-ADHESIONS—Inguinal hernia

P150—Surgical Complications Between Elderly and Young Patients After Inguinal Hernia Repair

Nubia Andrea Ramírez Buensuceso Conde ¹ , M.R. Rodríguez Luna¹, N. Pérez Carrillo², A. Cruz Zárate¹, J. Farell Rivas¹, J. Rosales Becerra¹

¹Hospital Central Sur de Alta Especialidad PEMEX, Surgery, Mexico, ²IRCAD, Surgery, France

Introduction: The risk of developing inguinal hernia increases significantly in the elderly due to loss of strength of the abdominal wall and intra-abdominal conditions. The purpose of this study is to compare the surgical complications that occur in patients older and younger than 60 years, after an inguinal hernia repair.

Methods: Retrospective study of 266 patients who underwent surgery for unilateral or bilateral inguinal hernia with the open Lichtenstein-type technique or the transabdominal preperitoneal laparoscopic technique (TAPP) during the period 2016-2019. In group 1, 172 patients aged 60 years or older were included, in group 2 93 patients who did not exceed that age. The variables studied in the two groups of patients were: repair technique, postoperative complications such as surgical site infection, cardiac event, seroma, hematoma and inguinodynia, and severity according to the Clavien Dindo scale. The statistical analysis was made with × 2 and OR in SPSS.

Results: The TAPP laparoscopic surgical technique was the most applied in both groups, 81.9% in those under 60 years of age and in older adults in 65.1%. The mean length of hospitalization in the group under 60 years old were 4 days and 3.4 days for the older group. The incidence of complications was higher in the group aged ≥ 60 (74.1%) compared to those ≤ 60 (25.9%) (p = 0.106) (Table 1). The percentage for seroma, hematoma, inguinodynia and cardiologic complications were higher in older adults (77.8%, 78.9%, 63.3% and 10.5%). The OR for cardiologic complications was 5.3 (CI:1.20-23.5). (Table 2) In the Clavien Dindo Score there was 26.1% in Grade I in the group under 60 years, and 31.2% in older adults. There were no deaths and only one case Grade IV A in older adults and one case IV B in patients under 60 years old. (Table 3) According to the surgical technique there was a lower frequency of complications in the TAPP technique 9.8% (17) compared to the open Lichtenstein technique 13.9% (24) in older adults.

Analysis: The mean length of hospitalization in the group under 60 years old were 4 days and 3.4 days for the older group without significant differences. The incidence of complications was higher in the group aged ≥ 60 (74.1%) compared to those ≤ 60 (25.9%) (P < 0.106). When divided there were higher percentages for seroma, hematoma, inguinodynia and cardiologic complications in patients aged ≥ 60 years, with no statistical significance. The most common complications were hematoma (78.9%) and seroma (77.8). For the Clavien Dindo Score there were more cases in the older group with p ≥ 0.05. The older adults has lower length of hospitalization than the younger group (3.4 vs 4.02; p = 0.48). When studying the risk we found being ≥ 60 years old as a risk factor for cardiologic events (OR: 5.3; CI:1.20-23.5). Which is an expected result for the older population.

Conclusion: In this study, it was determined that it is safe to perform inguinal hernia repair in patients over 60 years old. Although they have apparently more complications, being the most common hematoma and seroma, there were no statistical significance. Also there is no difference in the severity of these complications when compared with those of the < 60 years group according to the Clavien Dindo classification. TAPP surgery is the most widely used in our center and the safest for both groups with a low percentage of complications. Age should not be a contraindication for performing a laparoscopic inguinal hernia repair.

HERNIA-ADHESIONS—Inguinal hernia

P151—Mesh Splitting versus nonsplitting in Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Sherif Albalkiny ¹ , M. Qassem¹, G. Behairy²

¹Aneurin Bevan Health Board, General Surgery, United Kingdom, ²Ain Shams University Hospital, General Surgery, Egypt

Aim: Our research was performed to determine the effects of mesh tailoring and splitting to enclose the spermatic cord and to equate this technique in terms of risks, quality of life, and recurrence rate to the conventional transabdominal preperitoneal (TAPP) procedure.

Patients and methods: A total of 40 patients with mean age of 33.6 ± 8.8 years, ranging from 18 to 60 years, underwent laparoscopic hernia repair (TAPP), where group I underwent repair with mesh splitting technique, whereas group II underwent the standard TAPP approach without mesh splitting. All patients participated in the study completed 2 years of follow-up. Full clinical assessment for all patients was performed, and any postoperative complications such as postoperative pain, wound infection, seroma, hematoma, or recurrence were recorded. After 1 year, testicular perfusion was assessed as well. For evaluation of the quality of life, MOS 36- Health Survey (SF-36) was used.

Results: There was no significant difference between the two groups in terms of recovery time to normal physical activity. All patients reported that their chronic groin pain was reduced over time and completely disappeared after 6 months. The most common encountered complication was postoperative seroma, which occurred in 22 (55%) patients. In terms of incidence of recurrence, only one case was reported in group II after 3 months of follow-up.

Conclusions: No difference in postoperative complaints or complications was demonstrated with mesh splitting and fashioning in laparoscopic hernia repair. Moreover, proper surgical handling and reduction of suturing and fixation in addition to avoiding nerve and vessels injuries are the main keys to prevent post hernioplasty chronic pain. Additionally, this study could not demonstrate any effects on the testicular integrity from implantation of splitted or nonsplitted mesh.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P152—Early or Delayed Laparoscopic Cholecystectomy After Endoscopic Cholangiopancreatography and Papillotomy: Does It Make a Difference?

J. Grosek, A. Tomažič ¹

¹University Medical Centre Ljubljana, Abdominal Surgery, Slovenia

Background: Gallstones are one of the most common problems in the gastrointestinal tract. The incidence of gallstones has been increasing. Typically, gallstones occur in the gallbladder, however, they can also be found in the common bile duct. Endoscopic retrograde cholangiopancreatography with endoscopic papillotomy (ERCP/EPT) followed by a cholecystectomy is standard treatment of common biliary duct stones. It is unclear, however, what is the optimal time interval between ERCP/EPT and cholecystectomy. AIM. The aim of the study was to evaluate the current practice where patients are mostly operated one to three months after ERCP/EPT and to determine the optimal timing for the cholecystectomy after ERCP/EPT. We wanted to check if time interval between ERCP/EPT and cholecystectomy has any correlation with the rate of conversion, the duration of surgery and complications after surgery HYPOTHESIS. Our hypothesis was that the interval between ERCP/EPT and cholecystectomy has no effect on the rate of conversion, the duration of surgery and complications after surgery. The second hypothesis was that there are no differences in the rate of conversions and postoperative complications between the groups of patients operated within or after 6 weeks. We wanted to find the optimal time interval between ERCP/EPT and cholecystectomy.

Methods: We retrospectively analysed 117 patients who underwent a preoperative ERCP/EPT followed by a cholecystectomy in 180 days. Relationship between demographic characteristics, type and duration of operation, conversion rate, postoperative complications and interval time was tested by using multiple linear regression. The optimal interval was studied by drawing receiver operating curve (ROC) and studying the area under curve (AUC). The patient groups (operated within 6 or after 6 weeks) were compared with chi-square.

Results: The interval between cholecystectomy and ERCP/EPT did not have an effect on the number of conversions, duration of the operation or postoperative complications. There was no statistically significant relationship between any independent variable and time interval found. No threshold interval could be found that would discriminate whether a patient had operation conversion or complications or not. There were no statistical differences between the patient group operated within and after 6 weeks after the ERCP/EPT. CONCLUSIONS. We found no statistical significant correlations between the timing of cholecystectomy after ERCP with EPT and the rate of conversions, complications or operation duration. We cannot propose the optimal time for the surgery with our study. Larger prospective randomized trials are needed to determine optimal time interval between ERCP/EPT and cholecystectomy.

ROBOTICS & NEW TECHNIQUES—Bariatrics

P153—Prophylactic Doses of Tranexamic Acid (TXA) in Reducing Hemorrhagic Complications in bariatric surgery

Pawel Lech ¹ , N. D. G. Dowgiallo-Gornowicz¹

¹Miejski Szpital Zespolony w Olsztyn, Bariatric Surgery, Poland

Introduction: Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric surgery in the world. Although it appears to be a safe treatment for obesity, it is still at risk of complications. The latest literature shows that postoperative bleeding occurs in 2-4% of cases, and up to 3% of cases requires reoperation for hemostasis. The aim of the study is to assess the effect of tranexamic acid (TXA) on hemorrhagic events and the reoperation rate in patients undergoing LSG.

Methods: Comparison of two groups of patients 6 month prior and 6 month after bariatric surgery (after introducing the prophylaxis doses of TXA)

Results: 314 patients underwent LSG in a high-volume center from 2016 to 2017. After introducing TXA, a statistically significant reduction in the incidence of hemorrhage during surgery was observed (22.3% vs 10.8%, p = 0.006). There was a statistically significant reduction in the need for the staple line oversewing (10.2% vs 1.9%, p = 0.002). The mean operating time and the mean length of hospital stay were significantly higher in the non-TXA group than TXA group (63.1 vs 53.7 min, p < 000.1; 2.3 vs 2.1, p = 0.02). In both groups of patients, no venous thromboembolism or other complications occurred within 6 months after the surgery.

Conclusions: The prophylactic doses of TXA can reduce the hemorrhagic complications in the early postoperative period after bariatrci surgery

ROBOTICS & NEW TECHNIQUES—Basic and Technical Research

P154—Different Approaches of Videoscopic Para-aortic Lymphadenectomy and Para-aortic Node Sampling

Marta Włodarczyk ¹ , M. Jęckowski¹, J. Cywinski¹

¹Copernicus Memorial Hospital, Vascular, General and Videoscopic Surgery, Poland

Significant development of minimally invasive techniques paves the way for new approaches to aortic and iliac lymph node resection procedures for both diagnostic and therapeutic reasons. As they may prove beneficial in patients with haematological diseases and patients with gynaecological and urological malignancies requiring lymphadenectomy, two techniques were developed, namely extraperitoneal and transperitoneal videoscopic para-aortic lymph node dissection.

As the volume of the material aspirated by needle biopsy may be inadequate, videoscopic techniques allow the surgeon to obtain sufficient amount of lymphatic tissue. Therefore, it plays key role in the diagnostic process of patients with haematological diseases by eliminating the risk of delayed diagnosis due to the failure of fine needle biopsy. The therapy in this patient group may begin earlier, which is of greatest importance in lymphomas.

Being an alternative for open laparotomy, videoscopic procedure offers multiple advantages. The possibility to avoid large incision results in the reduction of postoperative pain, risk of wound infection and incidence of postoperative hernia in the future. When compared to open laparotomy, videoscopic approach improves postoperative patient mobilization and reduces the length of hospital stay. Consequently, the delay in the introduction of adjuvant treatment, e.g. chemotherapy, may additionally be avoided.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P155—The fibres of the circular junction of the linea alba in normal adult anatomy

Radhika Merh ¹ , D. Jenner¹, M. Saunders¹

¹The Conquest Hospital, General Surgery, United Kingdom

The linea alba (LA) is known to be useful to surgeons for making surgical incisions. Laparoscopic entry into the peritoneal cavity using the open technique may involve identification of a point just above or below the umbilicus where the peritoneum is fused to the LA. This anatomical site is found through superficial dissection to expose the junction between the umbilical stalk (US) and the LA, where distinct fibres seem to form a unique ligament-like structure in normal adult anatomy. This point, in fact, is part of a circular fibrous structure that exists almost like a ring around the remnant US. It is formed by the fusion of oblique and transverse fibres of the LA with circular fibres from proliferation of an encircling band of compact mesoderm to close a patent umbilical ring. We describe and name this anatomical landmark as junctio circularis alba or the ‘circular junction of the LA’ as encountered in normal adult human anatomy. We believe this is crucial for describing key surgical procedures at this site to aid effective surgical training and reduce iatrogenic complications from laparoscopic port site entries.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P156—Reduced neural activity during volatile compared to total intravenous anesthesia: evidence from a novel EEG signal processing analysis

Amitai Bickel ¹ , N. Maimon², L. Molcho³, N. Intrator⁴, S. Ivry⁵, A. Gavrilov⁵

¹Galilee Medical Center, Surgery A, Israel, ²School of Psychological Sciences Tel Aviv University, Psychology, Israel, ³School of Neuroscience, Tel Aviv University, Israel, ⁴School of Computer Science Tel Aviv University, Israel, ⁵Galilee Medical Center, Anesthesiology, Israel

Background: Post-operative cognitive decline is a well-known phenomenon and of crucial importance especially in the elderly, emphasizing the importance of selecting the proper anesthesia. General anesthesia can be accomplished by volatile or total intravenous (TIVA) anesthesia. Currently little is known about their influence on brain functionalities during surgery.

Aims: To assess differences in brain activity between volatile and TIVA anesthetics during surgery.

Methods: Patients who were electively scheduled for laparoscopic cholecystectomy gave informed consent to participate in the study, and were randomly divided to receive either volatile anesthesia (n = 9) or TIVA (n = 8). The level of anesthesia was kept to be equal in both groups. A single bipolar EEG electrode (Aurora by Neurosteer) was placed on the participants' foreheads. It presented real-time activity and collected their data during surgery. The dependent variables included frequency bands (delta, theta, alpha and beta), and three biomarkers that were previously extracted with the Aurora device and provided by Neurosteer.

Results: All surgeries were uneventful, and all patients showed bispectral index (BIS) less than 60. Biomarker activity under volatile anesthesia (in compare to TIVA) was significantly lower for the theta, delta and alpha frequency bands and for the three biomarkers (VC9, ST4, and A0). Further analysis showed that the largest difference between anesthesia types was for biomarker A0.

Conclusions: Both EEG frequency bands and novel brain activity biomarkers provide evidence that volatile anesthesia further reduces components of brain activity in comparison to TIVA anesthesia. Specifically, A0, which previously showed a correlation with cognitive decline severity and cognitive load, exhibited the most prominent difference between anesthesia types. Together, this study suggests that measuring brain activity during anesthesia using sensitive biomarkers, enables revealing that different anesthesia types may affect brain activity differently, which could affect the recovery from anesthesia, and consequently reduce post-operative cognitive decline.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P157—Proof of Concept for the Application of Fluorescence Lifetime Imaging (FLIm) In Colorectal Surgery

Deborah Keller ¹ , A. Alfonso-García², J.Y. Lee³, L. Marcu², B. Cummings¹, E.R. Raskin¹

¹University of California at Davis, Surgery, USA,²University of California at Davis, Biomedical Engineering, USA, ³School of Medicine, University of California at Davis, Medical Microbiology and Immunology, USA

Introduction: Fluorescence is a promising tool to improve surgical quality, but limitations in fluorophores, lack of sensitivity, and non-quantitative data with current platforms hamper utility. To address limitations, we developed an assessment technique using near-UV light that stimulates tissue autofluorescence- Fluorescence Lifetime Imaging (FLIm). FLIm detects dynamic spectral and temporal changes in tissue composition induced under pathological conditions. Benefits to FLIm from tissue autofluorescence include no need for exogenous contrast (label-free) and real-time data collection and visualization. Imaging is achieved with a sterilizable handheld probe that can be integrated with any operative platform. FLIm can discriminate between normal, malignant, fibrosed, and inflammatory tissue in humans and animal models. FLIm has been proven a sensitive intraoperative tool for solid brain and head and neck tumor delineation. There has been little application in gastrointestinal (GI) disease to date. The ability to discriminate normal from diseased tissue in the GI tract could add great value to current diagnostic and treatment practices.

The goal of this work was to establish the baseline of FLIm parameters (spectra and lifetime properties) in murine GI tissue. We hypothesized that FLIm technology would be adaptable to GI surgery with reproducible results.

Methods: The colorectum, ileum, and mesentery of 12 healthy mice (6 male, 6 female) were collected after necropsy and imaged with FLIm. The FLIm employed a raster-scanned optical fiber probe (400 µm diameter) for multispectral imaging over the visible spectrum (ch1 = 390/18 nm, connective tissue target; ch2 = 435/40 nm, NAD(P)H target; ch3 = 542/10 nm, FAD target; and ch4 = 610/70 nm, lipids/ porphyrins target). Channels were tuned to capture fluorescence from structural proteins collagen and elastin, cellular metabolic co-factors nicotinamide adenine dinucleotide (NADH) and flavin adenine dinucleotide (FAD), lipids, and porphyrins.

Results: On average, murine colorectal, ileal, and mesentery tissue exhibited distinct fluorescence lifetime in a spectrally dependent manner. At an individual level, colon and ileum samples presented a mid-section with longer lifetimes than the proximal and distal ends, from different arrangements in connective tissue. The mesentery had distinct areas with lifetime corresponding to simple mesenteric tissue, lymphovascular tissue, and interstitial fat. The patterns were consistent across gender and reproducible across subjects.

Conclusion: Fluorescence lifetime imaging (FLIm) was successfully adapted to GI tissue, defining the spectral and lifetime properties in a healthy animal model. With the feasibility proven in the GI tract, next steps will be determining the sensitivity of FLIm in colorectal disease states and human validation as an intraoperative guidance tool during colorectal surgery.

Fig. 2 Geographic distribution of reports included in review

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P158—Multimodal Prehabilitation to Improve Postoperative Outcomes After High Impact Surgery—Study Protocol of the F4S PREHAB Trial

Dieuwke Strijker ¹ , B. van den Heuvel², C.J.H.M. van Laarhoven¹, W.J.H.J. Meijerink²

¹Radboud University Medical Center, Surgery, The Netherlands, ²Radboud University Medical Center, Operating Rooms, The Netherlands

Background: High impact surgery for oncological diseases is associated with postoperative complications occurring in up to 60% of patients, leading into higher mortality rates, prolonged hospital stays and impaired quality of life (QoL). Prehabilitation, a process to optimize a patient’s preoperative functional capacity (Fig. 1), has led to a 35-51% reduction of complications after colorectal surgery. Therefore, prehabilitation promises to be an effective intervention to improve postoperative outcomes in various types of oncological surgery.

Methods: A stepped-wedge cluster randomized trial (Fig. 2) will be performed to demonstrate the effects of a multimodal prehabilitation program (exercise program, nutritional intervention, psychological support and smoking cessation support) on clinical outcomes across a wide range of oncological patients, diseases and procedures (open and endoscopic) (n = 2828).

Discussion: Multimodal prehabilitation is expected to reduce postoperative complications and length of stay. It may therefore result in lower mortality rates, improved QoL and reduced hospital costs.

Trial registration: Netherlands Trial Register: NL8699—date of registration: 5 June 2020

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P159—9 Years Experience of Robot-Assisted Surgery in Nuoro (Sardinia)

Giuseppe Esposito ¹ , F. Pulighe¹, A. Cruccu¹, C. De Nisco¹

¹San Francesco Hospital, Nuoro, General Surgery, Italy

Da Vinci surgical system has been introduced in General Surgery Unit Operation Theater since 2013.

Its utilization has grown up progressively up to nowadays, giving a strong contribute for gastrointestinal (GI) cancers treatment but also for GI's benign and funtional diseases.

Most of these interventions have been carried out for rettocolic cancer. Gastric cancer is gaining in importance of indication for robotic resection. The Abdominal wall repair, either for complex, post-incisional or recurrent hernia, could be a future area of interest for robotic surgery and also be used for residents and fellows education. Hepatobiliary and pancreatic surgery had a limited indication and utilization in our unit.

Since 2013 to 2021: 324 interventions have been realized as following.

Colorectal resecions: 102 right hemicolectomies, 6 left hemicolectomies, 39 Miles resections, 83 anterior rectal resections (68 with ileostomy)

Gastric resections: 33 subtotal gastrectomies, 4 atypical gastroresections for GIST, 3 total gastrectomies.

Abdominal wall repair: 12 groin hernia repair, 1 groin + ombelical hernia repair. 1 bilateral groin hernia + Spiegel hernia repair, 4 Rives repair, 2 IPOM plus repair, 3 abdominall wall repair for disaster post-incisional hernia.

For what concerns liver surgery: 1 liver resection for benign disease and 1 for cancer, 4 metastasectomies were executed.1 pancreaticoduodenectomy in 2014 have been esecuted. 2 duodenal resections were also performed.

Biliary tract pathologies had a small experimental indication: 1 colecistectomy and linfoadenectomiy with partial resection for cholecistic cancer, 1 robot-assisted cholecistectomy due to its complex anatomy.

2 splenectomies for hematological malignancies were executed.

Complex diaphragm repair for functional diseases: 1 median arcuate ligament resection for Dunbar syndrome, 1 diaphragmatic plastic plus Toupet gastroplasty could be included in this category.

Oesophageal robotic surgery has been rarely performed: 2 cases for benign functional disease were treated.

2 lung resections were also performed.

1 staging procedure has been made for pancreatic cancer (carcinosis was found intraoperatively)

Combined interventions for complex oncological resectionsis is a relevant application of robotic surgery. 7 of them were executed: with gynecologists (hemicolectomy + oophorectomy for rectal cancer) with both urologists and gynecologists (for infiltrating rectal cancer), with urologist (for infiltrating rectal cancer).

Last but not least, the robotic surgery is used in this centre also for metastatic disease and for contemporary pathologies: colic cancer with liver metastasis (3cases), 1 colic cancer + colecistectomy reported.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P160—A Preoperative Planning Tool for Lung Segmentectomy Procedures: A Case Study

S. Vermijs¹, Pieter De Backer ¹, B. Cornette², P. De Backer³, K. Decaestecker³, L. Desender², C. Debbaut¹

¹Ghent University, Department of Electronics and Information Systems, Belgium, ²Ghent University Hospital, Department of Thoracic and Vascular Surgery, Belgium, ³Ghent University Hospital, Department of Urology, Belgium

Aim: Both improvements in thoracoscopy and advanced imaging methods make lung segmentectomies increasingly prevalent. Preoperative 3D models aid in making these procedures safer. We set up a program of improving thoracoscopic safety at Ghent University Hospital using 3D models for lung segmentectomies.

Methods: Patients received a multidetector contrast-enhanced high resolution CT scan (slice-thickness: 1 mm). Mimics Innovation Suite (Materialise, Belgium) was used for creating a 3D model, mainly by using volume rendering methods: In this way, the bone structures, arteries, veins, bronchi, tumor and lung lobes were segmented. The segmentations of the bronchi and the lobe affected by the tumor were then used as input for a preoperative planning tool. Starting from the bronchi, a region growing approach divided the lobe volume into the lung segments. These segments were subsequently visualized on the 3D model, allowing the surgeon to determine the affected segment and the vessels perfusing this segment.

Results: In Fig. 1, a case study of a 56-year old patient with a suspected tumor in the left upper lobe is illustrated. Using the preoperative planning tool, the lung segments were determined (Fig. 2, top view). The 3D model aided in the correct identification of the affected segments, the respective bronchus and vascularization, leading to a safe resection of the apical and posterior segments (S1 and S2). The patient had an uncomplicated postoperative course.

Conclusion: The preoperative planning tool proved to be an added value during a successful first case at our center, providing in-depth insight in the patient-specific anatomy. This is an important step in aiding the surgeon to improve thoracoscopic safety, although further validation of the algorithm is necessary. In the future, surgical resection procedures in other organs, such as e.g. kidney or liver, could also benefit from this approach.

ROBOTICS & NEW TECHNIQUES—Colorectal

P161—Robotic Colorectal Cancer Surgery Offers Improved Early Post-operative Clinical and Oncological Outcomes

Athanasios Karategos ¹ , M. E. Elghobashy¹, B. L. Liu¹, N. Y. Yassin¹

¹Royal Wolverhampton NHS Trust, Colorectal Surgery, United Kingdom

Background: Robotic surgery represents the newest minimally invasive technology available to reduce the impact of surgery and provides unique benefits in pelvic access of the technically challenging colorectal resections. The purpose of this study was to assess the feasibility, clinical and oncological outcomes of robotic surgery for patients with colorectal cancer.

Methods: This is a single-institution prospective study evaluating all patients with colorectal cancer undergoing robotic resection between October 2020 to December 2021 at our trust. Demographic data, perioperative and 30-day postoperative outcomes were assessed. The feasibility techniques and clinical outcomes were documented and data were analysed.

Results: A total of 100 robotic cases were performed of which 68 are due to colorectal cancer. Fifty-seven per cent (n = 39/68) had sigmoid cancer followed by right sided colon cancer in 27%(n = 18/68) and rectal cancer in 20%(n = 14/68). The M:F ratio was 2:1, median age of diagnosis was 68 (36-88) years and BMI of 29 (18-41) kg/m2. Forty-two patients underwent Anterior Resection (34% High,28% Low), 17 (25%) Right Hemicolectomy, 3 (5%) patients underwent panproctocolectomy and 2 (3%) abdominoperineal excision. A covering loop ileostomy was formed in patients with low rectal cancer. There were no conversions to open surgery. Anastomotic leak (Clavien-Dindo grade IV) was noted in 1.4%(n = 1/68) of patients. Return of gut function, as defined by tolerating oral diet and passing flatus, was noted within 48 h in 91% of the patients (n = 62). All patients were discharged on their baseline Hb with no need for iron replacement therapy or blood transfusion. The median length of hospital stay was 5 days. Forty-four per cent of patients underwent adjuvant chemotherapy. Pathologically complete resection (R0) was achieved in all patients with a median lymph node ratio of 0.14. There was no reported 30-day mortality.

Conclusion: Robotic surgery for colorectal cancer is a feasible and safe approach ensuring that surgery remains minimally invasive, leading to a significant reduction in length of hospital stay, a rapid postoperative recovery and an earlier return of gut function.

ROBOTICS & NEW TECHNIQUES—Colorectal

P162—Robotic Ventral Mesh Rectopexy for Complete Rectal Prolapse

Serena Armentano ¹ , A. Marano¹, E. Gelarda¹, G. Preve¹, B. Vercellone¹, M. C. Giuffrida¹

¹ASO Santa Croce e Carle, Department of General Surgery, Italy

Aims: Complete rectal prolapse (CRP), is defined as a full-thickness protrusion of the rectal wall through the anus. The aim of treatment is to control the prolapse and relieve incontinence while preventing constipation. Ventral mesh rectopexy has gained acceptance for the correction of CRP, with minimal morbidity, low recurrence rate and postoperative constipation. The adoption of a robotic assistance provides comparable results to a laparoscopic approach with additional technical improvements,. We report a case of CRP successfully treated in our institution with a robotic ventral mesh rectopexy

Methods: A 80-year-old female otherwise healthy presented with severe constipation, with straining and fecal incontinence, mucoid discharge and tenesmus. Physical examination revealed a complete 8 cm-lenght external rectal prolapse, associated with a severe hypotonia of internal sphincter. Preoperative work-up included colonoscopy and anorectal manometry. The patient was considered suitable for robotic ventral mesh rectopexy

Results: A robotic daVinci Xi ventral mesh rectopexy was successfully performed. Critical steps of the procedure are described. After port placement, the uterus was lifted and peritoneum was divided starting from the sacral promontory; then the anterior rectal wall was fully mobilized from the vagina reaching the pelvic floor, leaving posterior and lateral attachments and preserving nerves. A titanium-coated light-weight polypropylene mesh (TiLoop®) was fixed to the anterior rectal wall and to the presacral fascia. Finally, the peritoneum was closed overlying the mesh. There were no intraoperative complications. The patient was discharged on postoperative day 2 after an uneventful course. At 6-month follow-up, the patient reported improvement of anal incontinence and had no further recurrence.

Conclusion: In our experience robotic ventral mesh rectopexy demonstrated as a safe and feasible procedure for the treatment of RP. Although current literature has not proven its superiority compared to laparoscopic approach, this technique may facilitate some surgical steps (i.e., dissection in a narrow pelvis, intracorporeal suturing and mesh fixation) improving surgeons’ performance.

ROBOTICS & NEW TECHNIQUES—Colorectal

P163—Intracorporeal Anastomosis Leads to a Quicker Recovery Following Both Laparoscopic and Robotic Right Hemicolectomy

Janina Kitow ¹ , M. Turina¹, A. Rickenbacher¹

¹Universitätsspital Zürich, Visceral- and Transplantation Surgery, Switzerland

Aims: In laparoscopic right hemicolectomy, extracorporeal anastomosis (ECA) has prevailed due to the complexity of performing laparoscopic intracorporeal sutures. Following robotic hemicolectomy, intracorporeal anastomosis (RICA) has gained more widespread acceptance, presumably due to the greater ease of intracorporeal suturing. Our study tests the hypothesis whether RICA offers improved short-term postoperative outcomes compared to laparoscopic extracorporeal anastomosis (LECA) in right hemicolectomy.

Methods: A retrospective analysis of our institutional database was conducted. All patients undergoing either robotic or laparoscopic right hemicolectomy for cancer between 2016 and May 2021 by one of two colorectal surgeons were included. Primary outcomes were days to flatus, days to soft diet and length of hospital stay. Secondary outcomes included length of operation, conversion rate, and the number of lymph nodes harvested.

Results: The study included 73 patients (41 in the robotic group, (RICA = 21, RECA = 20) and 32 in the laparoscopic group (LICA = 5, LECA = 27)). Time to soft diet was shorter following both robotic and laparoscopic intracorporeal anastomosis, compared to any extracorporeal anastomosis (2 vs 2.9 days; P = 0.04). Duration of hospital stay was shorter with RICA compared to LECA (days = 6.1 vs. days = 8.6 P = 0.0311). Lymph node yield was higher in both ICA groups compared to the ECA groups (26 versus 20, P = 0.0121),) and median operative time was significantly longer when performing an intracorporeal anastomosis (RICA: 252 min, LICA 225 min vs LECA 189 min, P < 0.01). There were no significant differences in days to full mobility, days to flatus, conversions, readmission rates and reoperations.

Conclusion: Robotic intracorporeal anastomosis following right hemicolectomy is associated with shorter recovery and hospital stay compared to resections with extracorporeal anastomoses. In addition, a trend to higher lymph node yields was observed which may be associated with improved oncologic outcomes. This study adds to previous reports documenting the superiority of the robotic approach in select subgroups of colorectal cancer patients, which should be identified more clearly in subsequent studies.

ROBOTICS & NEW TECHNIQUES—Colorectal

P164—Intra-corporeal or extra-corporeal anastomosis after a robotic-assisted or laparoscopic right-colectomy—a systematic review and meta-analysis

Ana Yankovsky, G.M. Milky², U.K. Kreaden¹

¹Intuitive Surgical, Global Evidence Management, USA, ²Intuitive Surgical, Global Health Economics and Outcomes Research, USA

Aim: Studies have shown the benefits of intra-corporeal anastomosis during minimally invasive right-colectomy. However, there is limited evidence that compares the clinical outcomes of robotic-assisted intra-corporeal (R-ICA), robotic-assisted extra-corporeal (R-ECA), laparoscopic intra-corporeal (L-ICA), or laparoscopic extra-corporeal anastomosis (L-ECA) in one analysis. The aim of the systematic literature review and meta-analysis was to compare the clinical outcomes after robotic-assisted or laparoscopic right-colectomy with intra-corporeal or extra-corporeal anastomosis.

Methods: We searched PubMed, Scopus, and Embase databases for studies published from January 1, 2010 to July 1, 2021. We included studies that compare robotic-assisted and laparoscopic right-colectomy with intra-corporeal or extra-corporeal anastomosis. Primary studies, such as randomized control trials, prospective and retrospective observational studies were included in the analysis. Two reviewers independently selected the studies, assessed the risk of bias, and performed the data extraction. Primary outcomes were: conversions, operative time, post-operative complications, surgical site infection, length of hospital stay, reoperations within 30-days, and incisional hernia within 30 days. A meta-analysis was performed using the RevMan 5.4 software. Weighted mean differences (WMD) were calculated for continuous variables and weighted odds ratios (OR) for categorical. A random effects model was used when heterogeneity was statistically significant and I2 statistic > 50%, otherwise a fixed effects model was assumed.

Results: After inclusion and exclusion criteria we identified 21 studies. All were retrospective cohort studies in design. Six studies directly compared R-ICA with R-ECA, eight compared R-ICA with L-ICA, nine compared R-ICA with L-ECA and only one study compared R-ECA with L-ECA. Robotic-ICA had longer operative times compared to L-ECA (WMD = 68.34, CI = (46.98, 89.70), p < 0.00001, I2 = 94%) and L-ICA (WMD = 68.47, CI = (52.89, 84.05), p < 0.00001, I2 = 86%), but similar to and R-ECA (WMD = 18.13, CI = (-1.81, 38.07), p = 0.07, I2 = 90%). Results of the further showed that conversion to open surgery is less likely to occur in the R-ICA group compared to L-ECA (OR = 0.23, CI = (0.12, 0.41), p < 0.00001, I2 = 0%), L-ICA (OR = 0.45, CI = (0.21, 0.95), p = 0.04, I2 = 30%) and R-ECA (OR = 0.06, CI = (0.01, 0.33), p = 0.001, I2 = 0%). Length of hospital stay (days) was significantly shorter in the R-ICA group compared to L-ECA (WMD = -1.01, CI = (-1.65, -0.38), p = 0.002, I2 = 69%) and L-ICA (WMD = -0.38, CI = (-0.69, -0.07), p = 0.02, I2 = 41%), but similar when compared to R-ECA (WMD = -0.58, CI = (-1.18, 0.03), p = 0.06, I2 = 77%). When comparing incisional hernia rate, the R-ICA approach had significantly lower rates compared to L-ECA (OR = 0.25, CI = (0.07, 0.93), p = 0.04, I2 = 0%) and R-ECA (OR = 0.12, CI = (0.04, 0.36), p = 0.0002, I2 = 0%). Six studies reported on the incisional hernia rate with most of the studies having a follow-up of 30 days after surgery. The rate of post-operative complications, reoperations and surgical site infection was similar across all groups.

Conclusion: Robotic-assisted right colectomy with intra-corporeal anastomosis may lead to less conversion rates, shorter hospital stay and lower rates of incisional hernias. Further prospective studies with longer follow up are needed to fully understand the benefits of robotic-assisted right colectomy.

ROBOTICS & NEW TECHNIQUES—Colorectal

P165—Selection of the Circular stapler for Rectal Surgery Based on Surgical Wall Thickness Using Intraoperative EUS and Real Time Feedback System

Mazaki Junichi ¹ , T. Ishizaki¹, R. Udo¹, T. Tago¹, K. Kasahara¹, H. Kuwabara¹, M. Enomoto¹, Y. Nagakawa¹, K. Katsumata¹, A. Tsuchida¹

¹Tokyo Medical University Hospital, Department of Gastrointestinal and Pediatric Surgery, Japan

Anastomotic leakage (AL) in rectal resection is a serious complication. Patient factors such as age and medical history, as well as surgical factors such as tension, blood flow, and mechanical strength of the reconstructed colon, contribute to AL. We focused on mechanical strength. After the mesentery was processed and the rectum was straightened to the state just before resectioning, intraoperative EUS was performed to measure the surgical wall thickness (SWaT) at three locations: anterior, posterior, and lateral walls. In the result, the thickness of the rectal wall was 2.3 mm in the median and 2.4 mm in the mean. We also used the real time feedback (RTF) system of the Signia stapling system, which can measure the pressure resistance of the colon wall in 4 steps (1-4), to measure the pressure resistance at the time of intussusception. In the result, rectal resistance to pressure was RTF:1/2/3 = 61%/31%/8%. Furthermore, there was a correlation between SWaT and RTF, but no correlation between SWaT and gender or BMI.

The selection of the height of the circular stapler at the time of rectal anastomosis with the circular stapler has been based on the surgeon's subjective judgment, such as gender, BMI, and the presence or absence of preoperative bowel obstruction, but our study suggests that this alone is not sufficient for appropriate selection. Our study suggests that intraoperative SWaT and RTF measurements can be used to make appropriate and well-founded choices.

ROBOTICS & NEW TECHNIQUES—Colorectal

P166—Robotic and laparoscopic approach in the surgical field of colorectal cancer

Igor Černi ¹

¹General and Teaching Hospital Celje, Slovenia, Department of Abdominal and General Hospital Celje, Slovenia

Introduction: The incorporation of robotics into a minimally invasive surgery platform is the newest advancement and has the potential to change medical field even more drastically with minimization-and possibility of elimination human error. In the last few years robotic surgery changed the surgery field us a mini invasive surgical technique, despite advantages of laparoscopic procedures especially in treatment of colorectal cancer. The purpose of this study is to analyze the differences between laparoscopic and robotic techniques for treatment of colorectal cancer in terms of oncological and clinical outcomes.

Methods: Clinico- pathological data of 158 patients surgically treated for colorectal deaseases in the period 2010-2018 with laparoscopy and robotic were analyzed. The procedures were right colonic, left colonic and rectal resections. A comparison betweem laparoscopic and robotic resections was made. The first robotic-assisted resection of rectum cancer with hybrid tecnhique we performed in our department in 2010. In may 2014 we started again and first total robotic-assisted resections of colon and rectum cancer were performed (single docking system). In the period 2014-2018, 61 patients were operated (48% female, 52% male), the average age was 64,5 years,. 62% had ASA clasification II. Colorectal carcinoma were presented in 76% patients, the others had diverticulosis and benign deasseases, 62% had carcinoma of rectum and rectosigma.. Retrospectively we analized laparoscopic operations as well in period 2010-2018. 97 patients were operated (63% male, 37% female), the average age was 66,5 years. 40% of the patients had ASA clasificatio III. Adenocarcinoma were presented in 80% patients, the others had diverticulosis and benign deasseases. The most common localizationi in robotic procedure were rectum (25%) and rectosigma (41%), while in laparoscopic operations was cancer of coecum and colon ascendens

Results: In all patients radical resection has been done.The average number of isolated lymphnodes in the robotic method was 18,5 while in laparoscopic method was 16,5. The hospitalization was shorter in robotic operated patients ( average 7,5 days), on the other hand the time of the robotic operations was longer than laparoscopic operations. Intraoperative blood loss was in the robotic method smaller ( 50-150 ml) in comparison with laparoscopic method (100-300 ml). Conversion to open surgery was in robotic method lower (4,5%) than in laparoscopic method( 7%). Laparoscopic method has more freqent complications 9 ( 10,3%) while robotic method 4 (9%).

In 8 years follow up 9 laparoscopically operated died (10,3%), ( 5 due to cardiovascular diease, 4 due to progression of disease). In this period 3 robotically operated patients died (6%), one due to progression of disease, the others due to cardiovascular disease. The most common operation was right hemicolectomy (46%) by laparoscopic procedure, in the robotic method was anterior resection of rectum (54%).

Conclusion: Laparoscopic and robotic-assisted surgery are safe and able tecnhiques for the treatment of essentially all colorectal conditions requiring surgical intervention. Because of its dexterity and three-dimensional view, the da Vinci system was particularly useful in specific stages of the procedure, e.g., takedown of the splenic flexure, dissection of a narrow pelvis, identification of nervous plexus, and handsewn anastomosis. The cost-effectiveness of the procedure still needs to be evaluated.

To determine suitable minimally invasive surgical approach, it is important to recognise the both laparoscopic and robotic surgeries, present benefits and limitations as compared with each other. Hence, the ideal approach should ultimately result in the use of tecnhique must approriate for the specific surgical indication.

ROBOTICS & NEW TECHNIQUES—Education

P167—Laparoscopic Approach for Treatment of Left Renal Vein Pathologies: Symptomatic Nutcracker Syndrome and Arteriovenosus Fistula—Single Center Experience

Mateusz Jęckowski ¹ , J. Cywiński¹, A. Piasecki¹, M. Stelągowski¹

¹Copernicus Memorial Hospital, Vascular, General and Videoscopic Surgery, Poland

Left renal veins pathologies are rare disorders with difficulties in diagnosis and limited treatment options. In our department two of it has been treated by laparoscopy.

Symptomatic nutcracker syndrome (NCS) is caused by compression of left renal vein. This pathology is classified into two types: first is caused by narrow angle between the superior mesenteric artery and aorta, the second is anatomical variant, when renal vein is localised between aorta and spinal column. NCS is diagnosed mainly as exclusion diagnosis in patients presenting symptoms as left flank pain, hematuria or vaginismus. Treatment experience in this field is collected mainly through open surgery techniques, in which open left renal vein transposition is considered to be the gold standard technique. However, we present our experience with laparoscopic treatment of 3 female Caucasian patients with symptomatic NCS. One patient suffered from left flank pain and two others from pelvic congestions syndrome (PCS).

Iatrogenic arteriovenosus fistulas of left renal vessels is a rare complication—just 68 cases have been described since the first raport in 1934. Cardiac failure or pseudoaneurysm is a frequent and serious sequel, therefore closure of the fistula is indicated. Endovascular or open approach are the most frequent therapeutic options. Fifty-nine year old Caucasian female with history of left nephrectomy due to pyonephrosis twenty-one years ago has been diagnosed with arteriovenosus fistula with pseudoaneurysm. In our department after endovascular treatment failure we decided to consider laparoscopy as another option.

Treatment in all cases has been performed without any intraoperative complications. Hospitalization went uneventfully with median stay of 5 days. Follow-up effect of treatment is good. In PCS patients complete resolution of symptoms followed by laparoscopic intervention was observed. Among other case reports, the data of laparoscopic treatment of NCS and arteriovenosus fistulas is very limited, but due to favorable length of hospitalization and less invasiveness it appears to be safe and effective method, although further research should be conducted.

ROBOTICS & NEW TECHNIQUES—Education

P168—Cultivating Self-assessment and Reflection on Intra-operative Decision Making by Group Surgical Coaching for Surgical Trainees

Chi-Chuan Yeh ¹ , I. Lai²

¹National Taiwan University Hospital, College of Medicine, National Taiwan University, Department of Surgery, Taiwan, ²National Taiwan University Hospital, College of Medicine, National Taiwan University, Department of Surgery, Graduate Institute of Anatomy and Cell Biology, Taiwan

Purpose: Surgeon's skills will directly affect the safety of patients. Poor non-technical skills are increasingly considered to be an important factor causing adverse events. Intraoperative decision making (IODM) deeply affects the patient's surgical outcome. How to make surgeons have the abilities of lifelong self-assessment and reflection for continuous improvement in IODM and surgical skills is an important issue. Video-based surgical coaching has the potential to improve the quality and safety of surgical care.

The aims of this study are establishing a framework of group surgical coaching (GSC) and evaluating the immediate effect of cultivating self-assessment and reflection on intra-operative decision making by using group surgical coaching for surgical trainees.

Materials and Methods: This study adopted a mixed method research design and recruited surgical residents and PGY trainees. The participants attended group surgical coaching sessions for six months. In each session, edited videos of participants’ clinical performance in the operating theatre were presented. The participants and the surgical coach focused on assessing the technical skills and IODM comments. The coaching session was facilitated by a surgical coach served by senior attending physicians for training participants to obtain the abilities of observation, reflection and self-assessment. Participants’ reflections were collected in the end of coaching section. The immediate benefits of the course was evaluated with the assessment tools of technical surgical skills and IODM and reflection recording. self-assessment, peer assessment and expert assessment were compared.

Results: Twelve surgical residents and PGY trainees participated in this study. 1/3 attended more than two sessions of GSC. Most credited the GSC allowed them to reflect on their surgical skills and IODM by editing and presenting the surgical videos. The feedback from the coach and peers motivated the participants to improve their surgical skills and IODM, especially among the junior trainees. The results of self-assessment were significantly lower than the assessments from peers and experts.

Conclusion: We have established a framework of group surgical coaching, cultivating surgical trainees’ abilities of self-assessment and reflection on intraoperative decision-making, which could be part of surgical training for trainees in order to improve their trainees’ self-learning and lifelong improvement.

ROBOTICS & NEW TECHNIQUES—Education

P169—Teaching Basic Robotic Surgical Skills: The Influence of Laparoscopy

Dan Alin Brebu ¹, S. Cuzmanov², E. Homorogan², A. Dobrescu³, C. Tarta³, G. Verdes³, G. Noditi³, A. Isaic³, V. Braicu³, C. Lazar², C.Duta³

¹Timisoara County Hospital/University of Medicine and Pharmacy Victor Babes Timisoara, Second surgical Clinic/ Department X., Romania, ²Second Surgical Clinic of the „Pius Brînzeu” Timioara County Clinical Emergecy Hospital, Timioara, Romania, Second surgical Clinic, Romania, ³„Victor Babe” University of Medicine and Pharmacy, Timioara, Romania, Department X, Romania

The aim of this study is to determine the learning curve for basic robotic surgical skills and if it is influenced by prior laparoscopic surgical skills. We designed a workshop with 40 participants, divided into four groups, 10 participants each: Group 1 with fifth and sixth year medical students (S), Group 2 with second and third year surgical residents (R2-3), Group 3 with fifth and sixth year surgical residents(R5-6) and Group 4 with young attending surgeons (AS). S group had no prior training in minimally invasive surgery, while the remaining three groups, allthough without prior training in robotic surgery, had experience in laparoscopic surgery according to their current current medical training level. The theoretical part was comprised of four courses lasting one hour each, over a period of ten days and one lecture with a duration of two hours with practical exemplification using the da Vinci® Xi surgical system (Intuitive Surgical®) and dV-Trainer® (MIMIC Technologies®), for each of the four groups. The practical part was comprised of two exercises: Peg Board 1 (PB1) and Vertical Defect Suturing (VDF). Results were analyzed via the data automatically generated by the simulator, and the aim for completion of training was set at a score of 90% or above for each exercise. We recorded two variables: total time (minutes) spent on the simulator and number of tries needed in order to reach this score. Statistical analysis showed no significant differences beetween the R2-3 and R5-6 groups for both variables, on both exercises. The S group’s results were significantly better PB1 regarding both variables (p < 0.05), while the AS group had significantly better results for both variables on VDF (p < 0.05). There were no other statistically significant differences. The time spent on the simulator for completion of the workshop had a median value of 39 min, while the number of tries had a median of 23. We conclude that the learning curve for mastering basic robotic surgical skills is 23 tries and is significantly influenced by prior skill level in laparoscopic surgery.

ROBOTICS & NEW TECHNIQUES—Education

P170—Application of Objective Clinical Human Reliability Analysis (OCHRA) Methodology for Near Miss and Error Analysis of Basic Robotic Surgical Skills

Matthew Boal ¹ , W. Ghamrawi¹, J. Gorard², F. Vlachou³, C. Selvasekar⁴, J. Khan⁵, D. Miskovic⁶, N. Francis¹

¹The Griffin Institute, Surgical Research, United Kingdom, ²University College London, Surgical Research, United Kingdom, ³Queen Mary University London, United Kingdom, ⁴The Christie NHS Foundation Trust, Surgery, United Kingdom, ⁵Portsmouth Hospitals NHS Foundation Trust, Surgery, United Kingdom, ⁶St Mark's Hospital, Surgery, United Kingdom

Aims: (I) to test the application of intensive formative assessment during basic robotic training and evaluate its impact on learning

(II) Apply Objective Clinical Human Reliability Analysis (OCHRA) to basic, generic robotic skills through video analysis

Method: 112 procedures of basic robotic skills in a simulation lab, assessing basic skills in Virtual Reality (VR) on the da Vinci Skills Simulator (dVSS) and in the dry lab where videos were formatively assessed using Global Evaluative Assessment of Robotic Skills (GEARS) tool as well as the VR scores. Tasks were recorded and analysed with OCHRA methodology. This intensive 5-day training programme had 7 participants ranging from complete novice residents to a specialist, all with no prior robotic experience. Tasks selected were Sea Spikes, Ring Rollercoaster, Needle Driving and Knot Tying. Assessments compared were VR, VR GEARS and Dry model GEARS scores of each task at the start and end of the week. VR and GEARS breakdown scores were analysed and correlated with the OCHRA score methodology developed for basic robotic skills. ANOVA test was used to compare day 1 and day 4 for significant improvement, with Pearson’s correlation coefficient used to compare the different objective assessments.

Results: Sea Spikes, Ring Rollercoaster, Big Dipper Needle Driver, Knot Tying average scores on day 1 VR were 56%, 14%, 41%, 19% respectively compared to GEARS assessment percentages of the VR video 63%, 55%, 73%, 62% and Dry models 64%, 67%, 69%, and 62%. Day 4 the average assessment scores were 65%, 47%, 67%, 64% for VR, GEARS VR scores 88%, 82%, 92%, 87% and for GEARS scores on the dry model 87%, 90%, 91%, 87%. The participants’ average scores comparing day 1 to day 4 across all four VR and Dry model tasks showed significant improvement (p = 0.003). A strong correlation shown between the objective assessment tools, VR scores to VR GEARS r = 0.84, VR scores to Dry GEARS r = 0.72 and VR GEARS to Dry GEARS r = 0.92.

Conclusion: This feasibility study demonstrates the effective application of formative assessment tools to aid learning of novice surgeons undergoing basic robotic surgery training. OCHRA methodology is applied to assess its feasibility for error analysis of basic robotic skills.

ROBOTICS & NEW TECHNIQUES—Education

P171—Criterion Validity for Assessment of Laparoscopic Skills; What do We Actually Assess?

Sem Hardon ¹ , Y. Chaouch¹, J. Luttikhold¹, T. Horeman¹, F. Daams¹

¹Amsterdam UMC—VU University Medical Center, Dept. of Surgery, The Netherlands

Aims: Technical innovations in simulation training for minimally invasive surgery have evolved rapidly over the past few decades. However, trainers still traditionally assess skills and readiness for surgery in the operating room using assessment forms. This study aimed to reassess the validity of the gold standard when compared to novel innovative assessment tools.

Methods: Laparoscopically naive surgical residents were enrolled in a three-week fundamental laparoscopic skills (FLS) course. Laparoscopic suturing was performed for pre- and post-course assessments. Performances were assessed using the Objective Structured Assessment of Technical Skills (OSATS) form, the ForceSense measurement system, and video analyses. Pre- and post-course comparisons for each tool were performed to determine the acquisition of technical competence. Moreover, these outcomes were compared and evaluated to assess the criterion validity.

Results: Twenty-four trainees performed pre-course and post-course suturing tasks. The post-course OSATS score increased by 7.7 point (p ≤ 0.001). Furthermore, a significant improvement was observed in the post-course task time (-41.5%, p = 0.001), left-hand depth perception (+ 11%, p = 0.020), and path length (-32.8%, p = 0.001), compared to the pre-course task. Trainees dropped their needle (-77.8%, p ≤ 0.001) or thread (-50.0%, p = 0.021) less often during the post-course task and were less likely to manipulate the tissue unnecessarily (-56.9%, p = 0.001). No significant correlations were found between post-course OSATS scores and neither post-course ForceSense parameters nor post-course cumulative errors obtained from video analysis.

Conclusion: OSATS, the ForceSense system and video analyses can accurately assess the extent to which FLS training prepares trainees for laparoscopic surgery. However, this study shows major differences among these assessment tools, which are commonly used to determine technical competence, according to criterion and construct validity assessment. Surgical trainers should be aware of these outcomes, and carefully choose according to the purpose of the assessment.

ROBOTICS & NEW TECHNIQUES—Education

P172—Learning at a Laparoscopic Skills Training Center

A. Lozano Nájera¹, Paula Martínez Pérez ¹, J.L. Ruiz Gomez², J.I. Martin Parra¹, P. Martínez Pérez¹, J.C. Manuel Palazuelos¹

¹Hospital Universitario Marqués de Valdecilla, General Surgery, Spain, ²Hospital de Sierrallana, Colorectal Surgery, Spain

Aims: Obtain the level of competence that general surgery resident physicians have achieved by developing a training program in a laparoscopic skill such as intestinal anastomosis performed in pelvitrainer with exvivo viscera.

Methods: From April 2016 to April 2021, 24 resident physicians have optionally performed a practical surgical training program. This program is composed for 3 training modules of 20 h each. None had done a laparoscopic intestinal manual anastomosis.

The quality of the anastomoses during training has been measured with an evaluation tool. The score obtained with this evaluation tool divides poor quality anastomoses (between 0-5 points), improvable (6-15 points) and optimal (16-20).

Results of anastomosis performed by expert surgeons were also obtained.

Results: The total number of anastomoses performed was 337. The mean size of the anastomosis was 47 mm. The number of anastomoses performed has been: 127 enteroenterics, 157 gastroenterics and 53 ileocolics.

The mean quality of the first anastomosis was 14.6 points while that the mean quality of the last anastomosis was 16.0 points. Mean time of the resident physicians has been 66.4 min. The mean time to the first anastomosis was 91.3 min while that the mean time of the last anastomosis was 53.1 min. Regarding the expert surgeons, they performed a total of 41 anastomoses. Thier average time being 44 min; and the total average quality score of 16.5 points.

The mean of operations on the first day was 1.94 anastomoses, while the mean on the last day was 2.78 anastomoses.

Conclusions: The surgical skills training program achieves improve their surgical skills, not only in quality but also in surgical time, achieving after the training results close to expert surgeons.

ROBOTICS & NEW TECHNIQUES—Education

P173—Laparoscopy Training for General Surgery Residents—The Impact of the COVID-19 Pandemic

Diana Schlanger ¹ , C. Popa¹, N. Al Hajjar¹

¹“Iuliu Haţieganu” University of Medicine and Pharmacy, Surgery, Romania

Aims: Minimally invasive surgery is essential to be properly taught to general surgery residents since it constitutes a major part of nowadays surgical practice. Laparoscopic training should take into consideration the need for practice and the longer learning curve as compared to open surgery. The COVID-19 pandemic has a great impact on the healthcare system and on medical education as well. Our study analysis the impact of the COVID-19 pandemic on the training process in laparoscopic surgery for young surgeons.

Methods: The present study is a comparative survey study, that analysis the views and activities of general surgery residents in laparoscopic surgery, in two different time periods: before the COVID-19 pandemic (2019—pre-COVID-19 era) and during the COVID-19 pandemic (2020—COVID-19 era). Two different questionnaires, containing questions regarding their day-to-day surgical practice, as well as extracurricular activities, have been developed and distributed to general surgery residents from 7 different hospitals belonging to one university center.

Results: There were 33 responders in the first survey, and 45 responders in the second one. The residents activated in the operating room 5 days per week in the pre-COVID-19 era, versus 3 days per week in the COVID-19 era (p < 0.0001). In the first period, 69.7% of participants considered that they have not gain sufficient laparoscopy training, while 71.1% had the same view in the COVID-19 period (p = 1). Most of the residents (91.1%) believe that their opportunities for training have been diminished during the COVID-19 pandemic. The possibility of extracurricular training has decreased during the COVID-19 pandemic, from 72.7% to 22.2% (p < 0.0001). Most of the participants (77.8%) consider that they might benefit from more extracurricular activities.

Conclusion: The surgical residents consider that the laparoscopic training that they receive is insufficient. The training process of young surgeons in laparoscopy has suffered important changes during the pandemic period, with a reduction of active participation in the operating room and less opportunities for extracurricular training. Active changes need to be done in order to better prepare young surgeons for minimally invasive surgery in their clinical practice.

ROBOTICS & NEW TECHNIQUES—Education

P174—A Feasible Training Program for Transanal Endoscopic Surgery

Călin Popa ¹ , D. Schlanger², A. Ciocan², E. Mois², V.Prunoiu³, F. Zaharie², I.C. Puia², N. Al Hajjar²

¹"Iuliu Hatieganu "University of Medicine and Pharmacy/Regional Institute of Gastroenterology and Hepatology, Surgery, Romania, ²Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, Surgery, Romania, ³Institute of Oncology Bucharest, Surgery, Romania

Aims: Transanal endoscopic surgery (TES) gained more interest and clinical applications in the last years. However, TES is a challenging technique, difficult to perform even for skilled laparoscopic surgeons, because of the reduced range of motion and particularities of movement patterns. A proper training is recommended before applying this technique in clinical practice. Our study has intended to develop a simple training program that recreates the intraoperative conditions and allows surgeons to start from basic exercises and to move on step by step to more complex techniques.

Methods: Our study is a prospective analytical study that enrolled surgeons with different backgrounds and laparoscopic skills, but with no experience in TES, in order to validate our previously developed training tubular system. Our training program proposed a series of exercises that targeted different skills (coordination, dissection, suturing), performed in tubular training platforms. Each exercise had a specific goal and a time frame for completion.

Results: Forty surgeons were enrolled in the study—12 residents in years 1 to 3 of their residency program (group A), 16 residents in years 4 to 6 of their residency program (group B) and 12 senior surgeons (group C). After performing each exercise for 3 times, most participants have improved their performance parameters by 40 to 55%. Each group had a different completion rate of the proposed exercises, the groups with previous laparoscopic experience have performed better: group B has performed more exercises by 30% compared to group A, while group C performed better by 16% compared to group B. The costs of developing each training tubular system were low, around 60 euros.

Conclusion: The proposed training program proved to be a simple and easy-to-use tool, with low costs, that contributed to improving TES skills for all participants, regardless of their previous experience. A good skill set in laparoscopic surgery contributes to a better performance of TES exercises. Overall, the training program seems to be a feasible training tool for TES.

ROBOTICS & NEW TECHNIQUES—Education

P175—Early Experience with Robotic Surgery During COVID-19 Pandemia. Still a Long Way To Go!

Sergio Rojas ¹

¹Hospital Angeles/Puebla, Gastrointestinal Surgery, Mexico

Robotic surgery has been approved and performed around the world for more than 20 years. In many countries as ours, there have been many difficulties including high cost, training and credentials for surgeons and nurses. We inform our early experience as well as all the drawbacks during this 2020—2021 period.

Material & methods: We started our training for the daVinci surgical system in simulators at the end of 2020. There were included 4 general surgeons, 1 oncology surgeon, 3 urological surgeons, 4 gynecologist surgeons. All of them practiced for a minimum of 2-3 months in order to obtain the online assessment of da Vinci/Intiuitive and the off-site training program for Console Surgeon in USA. After successfully completed the training all of them started with surgical practice in the Hospital under “proctor supervision” who has more than 50 cases/year of experience. All were consecutive cases approved by our hospital-robotic committee.

Results: From January to September 2021, we included 50 cases: 15 in general surgery, 6 in oncology surgery, 12 in urological surgeries and 17 in gynecologic surgery. Mortality 0%, Morbility 8%, Operation time: 2-5 h, hospital stay: 2 ± 1 days, overall cost: > 30%. Convertion to open surgery: 6%.

Conclusions: This early experience has demonstrated that robotic surgery can be performed safely in our hospital. Our group is very enthusiastic with the surgical system, and this new technology has permitted us to work as a multispecialty group. This early results are encouraging, but we have noticed the increases in overall cost, longer surgical time and not a real difference with the laparoscopic surgery performed for more than 3 decades in our practice. We are also aware of skepticism in the medical community, insurance carriers and patients. Our challenge will be in the future to demonstrate that robotic surgery is not only feasible and secure, but with experience is better than standard minimal access surgery for complex cases. Our goal will be a RCT in all surgical specialties involved to really prove the benefits for the patients.

ROBOTICS & NEW TECHNIQUES—Liver

P176—Role of Robotic Surgery in the management of benign hepatobiliary diseases

Eli Kakiashvili ¹

¹Galilee Medical Center, General Surgery, Israel

Background: recently robotic surgery has emerged as one of the most promising surgical advances. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (HBP) surgery remains relatively unexplored.

Our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies.

Methods: A retrospective analysis of a prospectively maintained database on clinical outcomes was performed for 32 consecutive patients that underwent robotic assisted surgery for benign HBP disease at Rambam Medical Center during 2013-2016.

Results: There were 32 robotic assisted surgical procedures performed for benign HBP pathologies during the study period. There were 4 anatomical robotic liver resections for symptomatic hemangiomas, 9 cases of giant liver cyst, 5 robotic assisted surgery for type I choledochal cyst, 3 case of benign (iatrogenic) common bile duct (CBD) stricture, 5 cases of robotic (CBD) exploration due to large intra choledochal stones and 6 cases of cholecystectomy for cholelithiasis. The median postoperative hospital stays for all procedures were 3.5 days (range 1–6 days). General morbidity (minor) was 2%. There was no mortality in our series.

Conclusion: Robotic surgery is feasible and can be safely performed in patients with different benign HBP pathologies. Further evaluation with clinical trials is required to validate it's real benefits.

ROBOTICS & NEW TECHNIQUES—Pancreas

P177—The Effectiveness of Fish-Mouth Suture of Pancreatic Stump for Pancreatic Leakage by Shuriken Shaped Umbilicoplasty Method in Laparoscopic Distal Pancreatectomy

Yoshinobu Sato ¹ , A. Obana², T. Matsumura², T. Suwa³

¹Kashiwa Kosei General Hospital, Hepato-Biliary Transplant Surgery, Japan, ²Kashiwa Kosei General Hospital, Hepato-Biliary Pancreatic Transplant surgery, Japan, ³Kashiwa Kosei General Hospital, General Surgery, Japan

Postoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) is a leading contributor to postoperative morbidity & mortality.

Review analysis showed that POPF depend more on underlying patients’ factors than surgical technique. (e.g. obesity, preop nutrition level)

Hence, there is no convincing evidence to support any one transection & closure technique over another in laparoscopic DP. (AIM) Which is better technique for pancreatic transection&closure; Linear stapler or fish-mouth closure? Regarding pancreatic transection & closure, did fish-mouth closure reduce POPF & inpatient stay compared with Echelon linear stapler? (Patients and Method) This is a case-series report. Through the electronic chart we selected retrospectively the 20 patients who underwent laparoscopic DP between May 2019 to Oct 2021 at our institution. The patients of Transect/w Stapler were 10 cases. The patients of Transect/ fish-mouth closure were 10 cases. (Results) Median age of Stapler group was 64 old. That of fish-mouth group was 69 old. BMI were 21.0(19.2-28.5) and 23.0(18.6-31.1) respectively. Thickness of Pancreas on portal vein was 9.95 mm(6.74-14.77) and 10.8 mm(7.45-15.5) respectively. The cases of POPF over 5000 of drain amylase were 3 patients and those of fish-mouth were 0. Those of post operative psudocyst were 5 and 0 respectively. Blood loss were 90 ml and 100 ml respectively. Operation time were 321 min and 345 min respectively. (Conclusions) It is true that this case-series study enrolled limited number of cases, but fish-mouth closure may decrease the risk of POPF and postop pseudocyst compared to stapler. To show superiority of fish-mouth over stapler, case-control study with more power or prospective study is warranted to control confounding factors.

ROBOTICS & NEW TECHNIQUES—Pancreas

P178—Mesopancreas Dissection in Robotic Pancreaticoduodenectomy

Bor-Uei Shyr ¹

¹Taipei Veterans General Hospital, Surgery, Taiwan

Purpose: Pancreaticoduodenectomy has been one of the most challenging surgical procedures. Pancreatic cancer is associated with dismal outcomes and surgery remains the main modality of treatment. R0 resection with a negative resection margin would be an essential factor for a long-term survival. Retropancreatic margin or the medial margin is the most common site of positive resection margin. Mesopancreas is considered as a fusion fascia formed embryologically during the development of pancreas. This mesopancreas lies posterior to the pancreas and contains pancreaticoduodenal vessels, lymphatics, nerve plexus and loose areolar tissue. There is an increased rate of R0 resection by total mesopancreas resection, which is considered as mesopancreas level III dissection.

Materials and Methods: The mesopancreas level III dissection includes excision of total mesopancreas and right circumferential tissues of superior mesenteric artery (SMA). This level III dissection with pure robotic approach was applied to those with preoperative diagnosis of pancreatic cancer or bile duct cancer. The surgical outcomes including surgical parameters and risks were evaluated and compared between level III and non-level III dissection RPD.

Results: Up to August of 2019, 266 cases of RPD were performed. level III mesopancreas dissection RPD took longer operation time, as compared with non-level III RPD (median: 10.4 vs. 7.4 h), but the yield of lymph node harvested was higher by level III mesopancreas dissection RPD (median: 23 vs. 16). There was no significant difference regarding blood loss (median: 230 vs. 160 c.c.), POPF (11.1% vs. 10.7%), DGE (0% vs. 3.8%), PPH (5.6% vs. 3.8%), and chyle leakage (16.7% vs. 16.4%) between level III and non-level III mesopancreas dissection RPD.

Conclusion: Mesopancreas level III dissection is technically feasible with acceptable surgical risks in RPD. Moreover, yield of lymph node harvested is higher by this mesopancreas level III dissection RPD.

ROBOTICS & NEW TECHNIQUES—Pancreas

P179—Comparison of Robotic and Laparoscopic Distal Pancreatectomy

Yi-Ming Shyr ¹

¹Taipei Veterans General Hospital, Surgery, Taiwan

Background: Warshaw technique has gained the favor of some surgeons due to its simplicity. Outcomes and surgical risks after robotic distal pancreatectomy with spleen preservation (RDP-SP) by Warshaw technique and with splenectomy (RDP-S) were compared.

Methods: All the data for patients undergoing robotic distal pancreatectomy (RDP) were prospectively collected. The incidence and clinical significance of spleen infarction and gastric varices after spleen preservation by robotic Warshaw technique were also evaluated.

Results: A total of 177 patients were included, including 65 RDP and 122 LDP. Conversion rate was 1.5% in RPD group and 3.6% in LPD, P = 0.653. Spleen-preservation by Warshaw technique was 45.9% in total, with 53.1% in RPD group and 41.7% in LPD, P = 0.157. RDP took less operation time than LDP, with median of 2.7 vs 3.5 h, P = 0.005. Overall, DP with splenectomy took more operation time than that with spleen-preservation, P < 0.001, but the difference regarding the operation time between spleen-preservation and splenectomy was only significant in LDP group, P = 0.003, not in RDP, P = 0.072. Splenectomy was associated with higher blood loss, as compared with spleen-preservation in both RDP and LDP groups. There was no surgical mortality in both groups, and surgical morbidity was of no significant difference between RDP and LDP. Post-operative pancreatic fistula was 22% for overall patients, with 17% in RDP, and 24% in LDP, P = 0.340. There was also no significant difference regarding PPH, wound infection, chyle leakage, and hospital stay. The hospital cost in RDP was much higher than that in LDP, with median of 13,404 vs 7,765 USD, P < 0.001.

Conclusions: Both robotic and laparoscopic surgeries work equally well for DP. LDP with spleen-preservation by Warshaw technique whenever possible and feasible for those benign or low malignant, is highly recommended in term of cost and blood loss.

ROBOTICS & NEW TECHNIQUES—Pancreas

P180—Delayed Gastric Emptying in Minimally Invasive Pancreaticoduodenectomy

Yi-Ming Shyr ¹

¹Taipei Veterans General Hospital, Surgery, Taiwan

Background: Delayed gastric emptying (DGE) is one of the most common and troublesome complications after pancreaticoduodenectomy. The mechanism remains uncertain.

Method: Patients with periampullary lesions undergoing robotic pancreaticouodenectomy (RPD) or open pancreaticouodenectomy (OPD) were included. A variety of clinical factors were evaluated for the risk of DGE.

Result: A total of 600 patients with periampullary lesions undergoing pancreaticoduodenectomy were enrolled in the study, including 409 (68.2%) RPD and 191 (31.8%) OPD. Forty-six (7.7%) patients were associated with DGE after pancreaticoduodenectomy. DGE occurred in 46 (7.7%) patients after pancreaticoduodenectomy. Patients presenting with nausea/vomiting tended to have DGE, 12.6% vs. 6.3%, p = 0.019. Patients with preoperative jaundice were associated with higher rate of DGE than those without, 9.9% vs. 5.2%, p = 0.023. Malignancy was a significant factor related to DGE which occurred in 8.7% patients, as compared with only 2.2% in patients with a benign lesion, p = 0.016. Patients with lymph node involvement had a higher rate (9.8%) of DGE than those without (5.6%), p = 0.035. DGE occurred only 4.4% in RPD group, much lower than 14.7% in OPD, p < 0.001. Intraoperative blood loss > 200 c.c. was the other intraoperative factor related to DGE occurring in 11.2%, as compared with 4.4% in those with blood loss < 200 c.c., p = 0.001. PPPD, operation time, vascular resection, and tumor radicality were not significant predictors of DGE. The overall surgical mortality rate was 1.8%. The morbidity rate was 57%, with 12.2% POPF, 5.8% PPH, 23.3% chyle leakage, 1.5% bile leakage, and 6.0% wound infection. None of these postoperative complications was significantly associated with DGE. Hospital stay was significantly longer in the group with DGE than without, 37 vs. 20 days (median), p < 0.001. After multivariate analysis by binary logistic regression, RPD was the only independent factors to be associated with lower incidence of DGE, as compared with OPD

Conclusions: jaundice, gastrointestinal upset (nausea/vomiting), malignancy, blood loss (> 200 c.c.), lymph node involvement, and OPD (14.7%) are risk factors for DGE after PD. RPD is associated with low incidence (4.4%) of DGE and is the most/only powerful independent predictor for low DGE after multivariate analysis (binary logistic regression).

ROBOTICS & NEW TECHNIQUES—Pancreas

P181—Clinical outcomes of robotic versus open pancreaticoduodenectomy: a systematic review of literature and defining a new therapeutic index

Artemis Mantzavinou ¹

¹Barts and the London School of Medicine and Dentistry, Queen Mary University, Medicine, United Kingdom

Background: Pancreaticoduodenectomy (PD) is a challenging procedure with peri-operative complications. Robotic surgery offers improved dexterity, visibility, and accessibility. Recently, many centres have reported improved clinical outcomes for robotic PD. We reviewed the safety and efficacy of robotic PD in comparison to open PD using ‘Therapeutic Index’ (TI).

Methods: A systematic review of the literature was conducted in various databases. Articles published between January 2010 and March 2021 reporting totally-robotic and open PD were included, according to PRISMA guidelines. The Cochrane tool was used for risk of bias assessment. We compared 30-day mortality rates (MR30), lymphadenectomy rates (LR), R0 resection rates (R0RR) and therapeutic index (TI). STATA 16.1 was used for statistical analysis.

Results: The four studies that met inclusion criteria included 5090 PDs, out of which 617 were totally-robotic (RPD) and 4473 were open (OPD).

Variance ratio tests demonstrated a)Higher TI for RPD versus OPD (1807.42 vs 1723.37, p = 0.86), b)Significantly smaller MR30 (2.50 vs 19.00, p = 0.0004), c)Significantly lower R0RR (130.50 vs 939.25, p = 0.00) and d)No significant difference in LR between RPD and OPD (35.63 vs 38.25, p = 0.81).

Meta-regression analysis showed a significantly higher TI coefficient of RPD than OPD (0.66 vs -0.40, p = 0.08, α = 0.1).

Conclusion: Our study suggests that robotic PD is safe and not inferior to open PD and our analysis RPD demonstrated a higher therapeutic index than OPD. Randomised controlled trials are required to establish the efficacy of robotic PD. Also, standardisation of reporting mortality, survival and oncological outcomes is needed for the effective calculation of TI.

ROBOTICS & NEW TECHNIQUES—Pancreas

P182—Full robotic pancreatoduodenectomy with the da Vinci Xi: a single surgeon's experience with the first 40 consecutive cases without conversion

L. Morelli¹, Matteo Palmeri ¹ , C. Carpenito¹, N. Furbetta¹, G. Di Franco¹, M. Palmeri¹, S. Guadagni¹, D. Gianardi¹, A. Comandatore¹, L.M. Fatucchi¹, F. Tarasco¹, G. Di Candio¹

¹University of Pisa, General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, Pisa, Italy

Aims: Robotic pancreatoduodenectomy (R-PD) has been demonstrated to be as feasible and safe as the open approach. Several studies have reported a learning curve for R-PD performed by a single surgeon that ranges from 20 to 40 cases, and a rate of conversion to open surgery that ranges from 1.1% to 5.1%. We report our experience with the first 40 consecutive R-PD performed by a single surgeon previously experienced in pancreatic surgery, and in robotic surgery for other indications.

Methods: A retrospective study of the first 40 consecutive cases of R-PD performed by a single surgeon from May 2018 to December 2021 in our Institution was conducted to evaluate the perioperative outcomes. Patients with pancreatic and periampullary tumours without vascular involvement were included in this study, regardless of BMI or previous abdominal surgery.

Results: Out of 40 patients undergoing R-PD, no one was converted to open surgery, despite 18 (45%) of them had undergone previous abdominal surgery, 14 (35%) had a BMI 25 kg/m²and < 30 kg/m²and 3 (7,5%) of them had a BMI 30 kg/m². Mean operative time was 434,9 112,1 min while mean console time was 282,7 39,5 min. The median postoperative stay was 10 days [8-21,75], 15 out of 40 patients were discharged within POD 8. Five patients (12,5%) had major complications (Clavien-Dindo grade 3 or above), while only 2 (5%) clinically relevant (grade B both) POPFs were encountered. There was no 30-day mortality. A full-robotic technique, both for the resective phase and for the reconstructive phase, was performed in all patients.

Conclusions: R-PD is a technically feasible and safe procedure for pancreatic and periampullary tumours. When an extensive previous experience in both pancreatic and robotic surgery is present, the da Vinci Xi platform allows to perform challenging procedures such as R-PD with a minimally invasive approach and low risk of conversion to open surgery, regardless of the learning curve specific for this procedure.

ROBOTICS & NEW TECHNIQUES—Pancreas

P183—Minimally Invasive Pancreatic Enucleation: Comparing Laparoscopic and Robot-Assisted Surgery

Elena Andreotti ¹ , E. Bannone¹, M. De Pastena¹, T. Giuliani¹, A. Balduzzi¹, C.C. Zingaretti¹, C. Filippini¹, R. Salvia¹, A. Esposito¹

¹AOVR Verona, Verona Pancreas Institute, Italy

Aims: The role and the indications for minimally invasive approaches in pancreatic enucleation (PE) have been poorly investigated. This study aims to compare laparoscopic (LPE) and robot-assisted (RPE) approaches for pancreatic enucleations.

Methods: Data from all consecutive patients undergoing minimally invasive PE from January 2008 to December 2020 were retrospectively analyzed. The patients were divided into two groups based on the surgical approach (LPE or RPE) and then compared. Preoperative characteristics, intraoperative findings, postoperative outcomes were prospectively collected and retrospectively analyzed.

Results: In the study period, 33 patients underwent minimally invasive PE, of which 22 (67%) LPE and 11 (33%) RPE. There was no difference in sex (p = 0.26), BMI (p = 0.19) and tumor size (p = 0.89) between the two groups. Compared to LRE, RPEs have been progressively adopted for pancreatic head lesions closer to the main pancreatic duct requiring the placement of Wirsung stents (0% vs. 27.3%; p = 0.03). This translates into a longer operative time in the RPE than the LPE group (130 min [IQR 95-160 min] vs. 200 min [IQR 175-316 min], p < 0.001). Despite no statistical differences in overall morbidity (27.3% in LPE vs. 54.5% in RPE, p = 0.14), RPE was associated with a longer length of hospital stay than LPE (9 days [6-19 days] vs. 6 days [5.7-7 days], p = 0.02).

Conclusions: Minimally invasive PE is a valid option for treating benign or pre-malignant pancreatic diseases. LPE is feasible and safe for more exophytic pancreatic lesions and is associated with short hospital stays. The RPE is a viable alternative for demanding procedures previously carried out by open surgery only.

ROBOTICS & NEW TECHNIQUES—Pancreas

P184—Dual-Console Robotic Surgery: a Safe Approach for Pancreaticoduodenectomy. A Retrospective Observational Study of 95 cases

Angela Tribuzi ¹ , G.G. Giuseppe¹, M. D. M. Di Marino¹, F.G. Guerra¹, A. C. Coratti¹

¹Misericordia Hospital, Usl Toacana Sud Est, Department of General and Urgency Surgery, Italy

Introduction: Pancreaticoduodenectomy (PD) is one of the most challenging abdominal procedures in surgical oncology. Due to the relatively new introduction in clinical practice together with its technical difficulty, the specific learning curve required to reach proficiency is still uncertain.

The availability of a second consolle in robotic surgery has a crucial role in enhancing training programs. However, there is still little to no data regarding the impact of a progressive introduction of junior surgeons in a dedicated program of robotic pancreaticoduodenectomy. We aimed to investigate the relative results of patients receiving robotic PD with a two-surgeon approach.

Methods: The perioperative details of all consecutive PDs performed by the same surgical along a 10-year time frame were retrospectively analyzed. A group of patients who underwent PD with a two-surgeon approach was compared to a group of patients who received PD by a conventional, single-surgeon procedure.

Results: A total of 95 patients receiving PD were collected. Some 33 patients received surgery with a dual-concolle technique, while 62 patients received surgery via a conventional, single surgeon PD. Baseline characteristics were well-balanced between the two groups. With the progressive introduction of junior surgeons during PD, no statistically significant difference was disclosed between the groups of patients treated by a single surgeon and those treated with a two-surgeon approach. In particular, no significant differences were found in terms of postoperative morbidity, unplanned conversion, length of hospital stay, and amount of lymph nodes harvested.

Conclusion: A dual-console approach for robotic PD is a safe, feasible, and reproducible platform of training. It does not impair the surgical and oncological standards of resection and allows a progressive technical growth of young surgeons.

ROBOTICS & NEW TECHNIQUES—Solid organs

P185—Reduced-Ports Robotic Pylorus-preserving Gastrectomy with Intracorporeal Gastro-gastrostomy for Early Gastric Cancer

S. H. Ahn¹, Nehal Jambi ¹ , S. H. Kang¹, E. Lee¹, Y. S. Park¹, S. H. Ahn¹, Y. S. Suh¹, H. H. Kim¹

¹Seoul National University Bundang Hospital, Surgery, Korea

Background: Laparoscopic gastrectomy has proven to be safe and effective as first-line treatment for early gastric cancer (EGC) in terms of oncologic Results: Although there still are controversies regarding the role of robotic gastrectomy for EGC, the robotic system offers stable 3D vision, near-infrared fluorescence imaging, and articulating wrist movements. These advantages make the robotic system suitable in performing reduced-ports robotic pylorus-preserving gastrectomy (RP-RPPG) with intracorporeal gastro-gastrostomy, which is a technically demanding operation. This study looks on the feasibility and safety of RP-RPPG for EGC.

Materials and Methods: Patients who underwent RP-RPPG at a single institution from March 2019 to November 2021 were enrolled. Electronic medical records were retrospectively reviewed for operative time, estimated blood loss (EBL), retrieved number of lymph nodes, postoperative hospital course, and early complications.

Results: RP-RPPG was performed on 65 patients with mean age of 57.2 ± 11.2 years and a body mass index of 23.4 ± 3.1 kg/m2. Three abdominal incisions were made, and a single-port device was inserted into the umbilical wound. There was no case of additional trocar insertion. The mean operative time was 187.4 ± 54.3 min., EBL was 31.1 ± 49.5 ml, and retrieved number of lymph nodes was 45.8 ± 14.3. In the final pathological stage, 57 (87.7%) were pT1, 6 (9.2%) were pT2, and 2 (3.1%) were pT4a. For N stage, 60 (93.8%) patients were node negative, and 4 (6.2%) patients were diagnosed pN1. The median postoperative day to first flatus was 3 days (range), to first soft fluid diet was 2 days (range), and the median postoperative hospital stay was 5 days (range). Four (6.2%) patients had early complication—two had unknown fever controlled with antibiotics, and other two had delayed gastric emptying which recovered within 3 days. There was no case of mortality.

Conclusion: RP-RPPG can be performed safely without increasing early postoperative morbidity.

ROBOTICS & NEW TECHNIQUES—Technology

P187—The Research Response to the Deficit of Pathological Models in the Intraoperative Ultrasound Training

Calin Tiu ¹ , T. Lango², J.M. Gjerde², M. Chmarra³, J. Dankelman³, S.M. Sánchez-Margallo⁴, J.A. Sánchez-Margallo⁴, A. Negoita-Tiu⁵, O. Madge⁵

¹Medis Foundation, Research, Romania, ²Norway, ³The Netherlands, ⁴Spain, ⁵Romania

The objective of the study: In recent years there has been an increase in the interest of surgeons and interventional radiologists to introduce various applications of ultrasound in their current practice. International impact societies such as the European Association for Endoscopic Surgery or locally, the Romanian Association for Endoscopic Surgery have initiated training projects aimed at increasing control and safety in minimally invasive surgery (MIS). An important limitation, so far, is that the hands-on programs are developed at the level of normal anatomical structures, lacking the possibility to reproduce pathologies that are relevant for the students.

Material and Methods: The recently launched European Research Project MIREIA aims to create training models for MIS using portable devices, augmented reality (XR) visualization technologies and 3D printed models. This will allow students to train in captivating virtual environments or physical simulators using customized 3D models having realistic (patient specific) pathology.

Results: At the stage of defining the pedagogical needs, it is expected that the project will respond to the interest of raising the fidelity in clinical and pathological level for a greater competitiveness of remote training in MIS.

Conclusions: The results of this project will bring a considerable benefit to training of technical and non-technical skills, including skills needed for intraoperative ultrasound guided procedures, by transferring hands-on activities to an environment equivalent to realistic pathological situations in MIS.

ROBOTICS & NEW TECHNIQUES—Technology

P188—Thoracoscopic Surgery of Large and Invasive Mediastinal Tumors

O. Usenko¹, Oleh Teslia ¹ , A. V. Sydiuk¹, O. Y. Sydiuk¹, A.S. Klimas¹, G. Y. Savenko¹, O. T. Teslia¹

¹Shalimov National Institute of Surgery and Transplantology, Department of the Thoraco-Abdominal Surgery, Ukraine

Mediastinal neoplasms are a key problem in the practice of thoracic surgeons. A characteristic feature of these formations is asymptomatic. The most common manifestations of the disease are the large size of the tumor, which causes compression of vital structures that are located in the mediastinum. Due to the widespread use of minimally invasive surgical methods of tumor removal, the question arises in the possibility of resection of large tumors of the mediastinum by thoracoscopic method. The advantages of thoracoscopy over open surgery are less pain and trauma, better cosmetic effect, faster rehabilitation period, especially for the elderly and patients with cardiopulmonary pathology. The aim of this work was to analyze the results of surgical treatment of large and invasive mediastinal tumors using thoracoscopic access. The study is based on the materials of clinical examination and surgical treatment of forty patients with mediastinal tumors who were examined and hospitalized in the thoracoabdominal department of the Shalimov National Institute of Surgery and Transplantology for the period from 2019 to 2021, among which the largest share is large (diameter > 5 cm), as well as invasive tumors. An analysis of the treatment of large, small (diameter < 5 cm) and invasive mediastinal tumors, which were removed by thoracoscopic method. The results of this study indicate that thoracoscopic interventions for large and invasive mediastinal tumors do not significantly increase the duration of surgery, postoperative recovery. Evidence of the safety and reliability of thoracoscopic surgery is the absence of significant complications.

According to the results of research by world experts, and the results of treatment of patients in the thoracoabdominal department of the Shalimov National Institute of Surgery and Transplantology it is proved that thoracoscopic surgery reduces the length of stay of patients in the hospital, causes fewer postoperative complications compared to traditional thoracotomy or sternotomy.

ROBOTICS & NEW TECHNIQUES—Technology

P189—Where is the cord? An ICG Overview in Laparoscopic Varicocele Ligation

A. Bhandarwar¹, Shalmali Dharmadhikari ¹ , G. Bakhshi¹, R. Gajbhiye¹, A. Wagh¹, S. Jadhav¹, A. Tandur¹, S. Bhondve¹, N. Dhimole¹, K. Reddy¹, G. Bharadwaj¹, A. Dutt¹, H. Padekar¹, R. Bhat¹, B. Ganesan¹

¹Grant Medical College, General Surgery, India

Background: Varicocele, the abnormal dilatation of the pampiniform plexus, can be treated by microsurgical subinguinal (Goldstein), inguinal (Ivanissevich), abdominal (Palomo, nonartery sparing) and endoscopic approach. Laparoscopic varicocele ligation is a long tried and tested treatment modality for varicocele. Indocyanine green (ICG) is a water-soluble dye which has the property of fluorescence enabling it to emit fluorescent radiation when excited by a laser beam or when exposed to near-infrared light (NIR) at about 820 nm and longer wavelengths. The difficulty in identifying the testicular vessels, which should be spared, can be reduced by the use of intraoperative indocyanine green angiography (ICGA).

Method: A prospective study was conducted in a tertiary care hospital. 60 cases with varicocele of grade 3 and above were selected. Through randomisation, using clinstat, 30 cases (Group B) were taken up for intraoperative ICGA after a subdermal test dose was given a day prior to surgery. The remaining 30 cases(Group A) underwent laparoscopic varicocele ligation without ICGA visualisation. Ports placed in the supraumbilical, suprapubic and on the ipsilateral side of the varicocele, lateral to epigastric vessels. After exposing the testicular vessels, ICG was injected intravenously in 30 of the 60 cases and both artery and vein visualised with fluoroscopic guidance. Vein was ligated with preservation of the artery and lymphatics.

Result: The testicular artery was clearly identified by ICGA and the veins were ligated, while preserving a few lymphatic vessels and the spermatic duct. The preserved arteries were confirmed by repeated ICGA at the end of operation. The mean time to the arterial phase (AP) from the ICG injection was 30.2 s and the mean time to the venous phase was 42.6 s. The mean interval from the arterial phase to the venous phase was 23.3 s. This time interval was utilised in proper identification. With no dye related complication, there was infection at operated site seen in 10% cases in Group A and 6.6% in Group B. Hydrocoele was seen in 1.4% cases who underwent with laparoscopic varicocele ligation. There was a decrease in post-operative complications such as recurrence and hydrocoele in the cases that were operated with ICGA.

Conclusion: ICG angiography is a safe and convenient modality that allows easier identification of vascular anatomy and provides and overall heightened surgical performance in difficult cases. It helps in reducing postoperative complications that could occur due to unaware injury to the testicular vessels and lymphatics.

ROBOTICS & NEW TECHNIQUES—Technology

P190—Releasing the band of pain: A Laparoscopic approach to Median arcuate ligament syndrome

A. Bhandarwar¹, Girish Bakhshi ¹ , R. Gajbhiye¹, A. Wagh¹, S. Jadhav¹, A. Tandur¹, S. Bhondve¹, N. Dhimole¹, K. Reddy¹, G. Bharadwaj¹, S. Dharmadhikari¹, A. Dutt¹, H. Padekar¹, B. Ganesan¹, R. Bhatt¹

¹Grant Medical College and Sir JJ Group of Hospitals, General Surgery, India

Background: Median arcuate ligament syndrome (MALS) is a clinical syndrome characterised by the compression of the celiac artery by the median arcuate ligament due to the fibres of this ligament that connect the diaphragmatic crura on the two sides of the aortic foramina, forming the anterior edge of the aortic foramina. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. Surgical repair in MALS by laparoscopy can be done to relieve the pressure over the artery. The purpose of this study was to review our experience of the laparoscopic management of MALS, and its outcomes after surgical intervention.

Method: After diagnostic workup and confirmation of MALS, 14 cases were taken up for laparoscopic decompression of median arcuate ligament over celiac artery. There were two approaches to the median arcuate ligament considered, with relation to the stomach- an anterior approach in 11 cases and posterior approach in 3 cases by hitching the stomach towards the anterior abdominal wall. Coeliac ganglia were removed to enable better decompression and pain relief. On table repeat indocyanine green angiography was performed 3 times to confirm the release on the celiac artery. Postoperative stay was monitored and pain measured as per visual analogue scale.

Result: Laparoscopic release of median arcuate ligament was shown to cause a decrease in pain postoperatively in 78% (11 out of 14) cases. The common intraoperative complications included bleeding in 28%(4 out of 14) and pneumothorax in 14%(2 out of 14). There was a conversion of laparoscopy to open surgery in 21%(3 out of 14) cases due to bleeding. Postoperative complications included pancreatitis in 1 patient and surgical site infection in 2 patients. Dumping syndrome was seen in 35%(5 out of 14) cases while recurrence was seen in 21%(3 out of 14) patients.

Conclusion: The available evidence shows that laparoscopic ligament release and celiac ganglionectomy with celiac artery revascularization can bring about effective symptom relief in the majority of patients diagnosed with MALS. With good patient prognosis and minimal post operative complications, it can be effectively used for MALS.

SOLID ORGANS—Adrenal

P192—Laparoscopic transabdominal excision of large malignant oncocytoma

Tarek Khalil ¹ , R.S. Shalaan¹, D.U. Diana¹, S.B. Siara¹, D.F. Don², M.E. Mohammed¹, S.A. Sebstain³, S.Z. Zino¹

¹Ninewells, Gen Surg, United Kingdom, ²Ninewells, Pathology, United Kingdom, ³ARI, gensurg, United Kingdom

Aims: Adrenal oncocytoma is a rare non-functioning benign unilateral tumour. Oncocytoma are epithelial tumours composed of cells with abundant eosinophilic granular cytoplasm packed with mitochondria. Oncocytoma occurs in kidney, salivary glands, parathyroid, lung, pituitary, ovary and rarely in the adrenal. Large adrenal incidentaloma > 4 cm raise the possibility of malignancy. Malignant oncocytoma are extremely rare tumour with limited knowledge about their behaviour

In this abstract we describe as rare case of large left adrenal Oncocytoma with high malignancy potential that was completely resected laparoscopically

Results: We present a case of a 73-year-old male patient who was admitted to the hospital with pneumothorax. A CT scan showed an incidental adrenal lesion measuring 8 × 6x9cm. The analytical studies showed a positive PET scan without any metastasis, and a negative MIBG scan with normal hormonal profile. laparoscopic approach was adopted despite pre-operative possibility of adrenal cortico-carcinoma was suspected. The lesion was removed completely with an intact capsule laparoscopically. Patient had an uneventful post op recovery and discharged home on post op day 5. Pathology reported the resected adrenal mass that was weighing 416 g and measuring 116 × 110 x 74 mm as oncocytic adrenocortical neoplasm satisfying the Lin-Weiss-Bisceglia criteria for diagnosis as an oncocytic adrenocortical carcinoma. One lymph node was free of metastasis. Regional MDT decided against chemotherapy or radiotherapy. Follow up with a 6 month post op CT was satisfactory with no evidence of recurrence or distant metastasis

Conclusion: Malignant oncocytoma are rare with no standard follow up protocol. 6 month interval CT might be necessary in the first two years post operatively. Complete surgical resection remains the main treatment. In this case we support that Laparoscopic approach is safe for complete oncological resection for large potentially malignant adrenal lesion

SOLID ORGANS—Adrenal

P193—Unusual case of primary adrenal squamous cell carcinoma

Diana Wu ¹ , S. Elbakri¹, T. Khalil¹, M. Elsllabi¹, R. Shaalan¹, J. Milburn², G. Athanasiadis², S. Aspinall², S. Zino¹

¹Ninewells Hospital, General Surgery, United Kingdom, ²Aberdeen Royal Infirmary, General Surgery, United Kingdom

Aims: The adrenal gland is commonly a secondary metastatic site of squamous cell carcinoma (SCC), however primary adrenal SCC has only been reported once previously in the literature. Here we present an unusual case of primary adrenal SCC.

Methods: A 72 year old woman presented with significant left sided flank pain and weight loss. Imaging revealed a heterogenous left adrenal nodule 4.2 cm in diameter with areas of necrosis. Plasma metanephrines, urinary steroid profile, urinary free cortisol, androgen profile and aldosterone renin ratio were all normal. FDG PET scan did not show any other obvious primary lesion. The patient had no other past medical history except for being an ex-smoker of 20 cigarettes per day from the age of 20 to 60. She was independent and lived at home with her husband.

Results: The patient underwent laparotomy and intraoperatively the adrenal mass was found to have infiltrated the left kidney, tail of pancreas and spleen. Therefore, left adrenalectomy, left nephrectomy, distal pancreatectomy and para-aortic lymph node dissection were performed en-bloc (Fig. 1). Her post-operative recovery was delayed by an intra-abdominal collection which was treated conservatively with antibiotics. Histopathology results showed SCC which was completed excised, with one of thirty lymph nodes involved. Since the occurrence of primary SCC of the adrenal gland is extremely rare, the patient was followed up with further CT chest, abdomen, and pelvis 3 months post-operatively, however no other lesion was found.

Conclusion: This case demonstrated an unusual case of SCC in the adrenal gland with no obvious other primary lesion at the time of presentation. To our knowledge this is the second case of this kind to be reported.

SOLID ORGANS—Adrenal

P194—Laparoscopic Transperitoneal Adrenalectomy- Outcomes After Resection of Increased Size- and Malignant Lesions

Aurel Ottlakan ¹ , A. Paszt¹, Z. Simonka¹, S. Abraham¹, B. Borda¹, M. Vas¹, A. Balogh¹, G. Lazar¹

¹University of Szeged, Surgery, Hungary

Aims The analysis of operative- and perioperative outcomes for lesions with increased size- and malignancy, in cases of laparoscopic transperitoneal (TP) adrenalectomy.

Methods Data of 135 patients undergoing laparoscopic TP adrenalectomy during a 20 year period has been analyzed. Both operative- (intraoperative blood loss, previous abdominal surgery, conversion rate, operative time, tumor size) and perioperative parameters [body mass index (BMI), American Society of Anesthesiologists (ASA) score, hospital stay, histology) were analyzed for malignant, large (LA) (6-10 cm) and extra-large (ELA) (10 cm <) lesions.

Results Out of a total 135 procedures, 18 malignant lesions (13,33%) were removed during TP adrenalectomy (11 metastasis, 6 adrenocortical carcinoma, 1 leiomyosarcoma). Complete, R0 resection was carried out in each case. Mean size of malignant lesions was 79.94 mm, previous abdominal surgery occurred in 77.77%, conversion was needed in 11.11%, mean intraoperative blood loss was 59.16 ml, mean hospital stay was 5.8 days, with mean operative time of 85.5 min. Among the 47 increased size lesions (LA: 40 vs ELA: 7), mean tumor size was 71.85 and 141.57 mm, rate of previous abdominal surgery 12 (30%) vs 5 (71.42%), mean intraoperative blood loss 64.47 ml vs 71.85 ml, hospital stay 5.10 vs 4.57 days, mean operative time 76.52 vs 79.28 min, mean BMI 23.45 vs 27.87, and mean ASA score 2.62 vs 2.42 for LA and ELA lesions, respectively. In terms of malignant lesions, 1 adrenocortical carcinoma and 4 metastases occurred in the LA-, and 3 adrenocortical carcinomas in the ELA group. Three ELA lesions (2 adrenocortical carcinomas and 1 neurofibroma) were removed through an additional mini-Pfannenstiel incision.

Conclusion Transperitoneal laparoscopic adrenalectomy proves to be a safe and feasible method in the removal of large-, extra-large-, and even malignant lesions. During the resection of malignant lesions, oncological radicality with complete resection is to be considered a priority.

SOLID ORGANS—Adrenal

P195—Body Mass Index and Postoperative Outcomes of Patients with Laparoscopic Adrenalectomy. A Single Center Experience

Flaviu Ionut Faur ¹, I. Nati², L. Stoica³, C. Tarta³, M. Marian³, A. Isaic³, C. Duta⁴, A. Dobrescu⁴

¹Pius Brinzeu Clinical Hospital Timisoara, II nd Surgery Clinic, Timisoara Emergency County Hospital, Romania, ²Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania, ³Timisoara Emergency County Hospital, Romania, II nd Surgery Clinic, Timisoara Emergency County Hospital, Romania, Romania, ⁴”Victor Babes” University of Medicine and Pharmacy Timisoara, Romania

Objectives: Laparoscopic adrenalectomy has become the standard of care for resection of adrenal masses with extremely low morbidity and mortality. This study investigates the difference in outcomes in patients who underwent laparoscopic adrenalectomy, comparing obese with non-obese patients.

Methods: This is a prospective study between 01.01.2017—31.12.2019. Setting: Pius Brinzeu Clinical Hospital Timisoara, Romania that includes 69 laparoscopic adrenalectomies. Selection criteria: Minimally invasive adrenalectomy (tumor size bellow 10 cm). All patients were managed by a constant surgical team, in the General II nd Department of Surgery of the Pius Brinzeu Clinical Hospital Timisoara, Romania. The preoperative workup and postoperative follow-up was performed in over 96% of cases in our department and in the endocrinology department of our hospital. In this article all values are presented as mean ± standard deviation for continuous variables, or percentages for categorical variables.

Results: The mean age of the patients population was 53.2 ± 9 years old. The mean diameter of adrenal glands resected was 5.2 ± 3.4 cm with a higher proportion of masses resected were left sided 53.62%, 46.37% right sided. The largest percentage of these lesions were adenoma (44.92%), aldosteronoma (20.28%), pheocromocythoma (13.04%), angiomyolipoma (17.39%) and ganglioneuroma (4.3%). Median operative time for our patient population was 123.5 min (range 96-165 min), while median estimated blood loss (EBL) was 52 ml (range 30-350 ml). The median length of stay (LOS) was 2 days (range 1-5). Adjusting for sex, the final logistic regression model predicting 30-day complications found obese patients were significantly (P = 0.036) more likely to have complications compared to non-obese patients. Women were significantly (P = 0.042) more likely to have 30-day complication (OR = 3.91, 95% CI = 1.32 11.47). The final regression model for LOS had no significant predictors. Obesity status was significant in predicting major postoperative complications (n = 8, 19.04%).

Conclusions: Laparoscopic adrenalectomy can be performed in non-obese as well in obese patients. Although there is a statistically increase in intraoperative and major postoperative complications for obese patients undergoing laparoscopic adrenalectomy, the clinical significance seems less obvious as it was shown that the laparoscopic approach has fewer complications than open surgery has. These results should rather challenge physicians to optimize obese patients prior to surgical intervention to avoid such complications.

SOLID ORGANS—Gynaecology

P196—CDK5RAP3 Acts as a Tumour Suppressor in Gastric Cancer Through the Infiltration and Polarization of Tumour-Associated Macrophages

You-Xin Gao ¹ , Y. X. Gao¹, K. Weng¹, H. G. Wang¹

¹Fujian Medical University Union Hospital, Gastric Surgery, China

We have demonstrated that CDK5RAP3 exerts a tumour suppressor effect in gastric cancer, but its role in regulating tumour-associated macrophages (TAMs) has not yet been reported. Here, we show that CDK5RAP3 is related to the infiltration and polarization of macrophages. It inhibits the polarization of TAMs to M2 macrophages and promotes the polarization of the M1 phenotype (Fig. 1A-E). CDK5RAP3 reduces the recruitment of circulating monocytes to infiltrate tumour tissue by inhibiting the CCL2/CCR2 axis in gastric cancer. Blocking CCR2 reduces the growth of xenograft tumours and the infiltration of monocytes. CDK5RAP3 inhibits the nuclear transcription of NF-κB, thereby reducing the secretion of the cytokines IL4 and IL10 and blocking the polarization of M2 macrophages. In addition, the absence of CDK5RAP3 in gastric cancer cells allows macrophages to secrete more MMP2 to promote the epithelial-mesenchymal transition (EMT) process of gastric cancer cells, thereby enhancing the invasion and migration ability (Fig. 2A-C). Our results imply that CDK5RAP3 may be involved in the regulation of immune activity in the tumour microenvironment and is expected to become a potential immunotherapy target for gastric cancer.

SOLID ORGANS—Parathyroid

P197—Preoperative Combined Ultrasonography and Sestamibi Scintigraphy is an accurate Measure in Preoperative Localization of Hyperparathyroidism

Sherif Albalkiny ¹ , G. Samaan², H. Hanna²

¹Aneurin Bevan Health Board, General Surgery, United Kingdom, ²Ain Shams University Hospital, General Surgery, Egypt

Aim: to detect the importance of combination of Ultrasonography and Sestamibi scintigraphy in the preoperative localization of patients with hyperparathyroidism to increase the adoption of minimally invasive Para thyroidectomy techniques.

Methods: A Prospective study included 40 patients who were admitted to Ain shams University Hospitals between January 2016 and January 2018. These patients were biochemically proven to have hyperparathyroidism in a non-randomized non controlled clinical trial. All patients underwent bilateral four gland exploration.

Results: The efficacy of the preoperative localization studies has been prospectively evaluated and correlated with intraoperative finding, pathological examination of removed gland and post-operative calcium level and parathyroid hormone level.

Conclusion: The combined Ultrasonography and Sestamibi scintigraphy in the preoperative localization of hyperparathyroidism is accurate in 90% of cases which in consequences will increase the adoption of minimally invasive Para thyroidectomy techniques which will provide the advantages with regard to cosmetic result, length of hospitalization, and reduced post-operative pain.

SOLID ORGANS—Spleen

P198—‘Salvaging the Spleen’—A Spleen Preserving Approach in Splenic Cysts

A. Bhandarwar¹, Shalmali Dharmadhikari ¹ , G. Bakhshi¹, R. Gajbhiye², A. Wagh¹, A. Tandur¹, E. Arora¹, S. Bhondve¹, N. Dhimole¹, G. Bharadwaj¹, K. Reddy¹, S. Dharmadhikari¹, H. Padekar¹, A. Dutt¹, R. Bhat¹

¹Grant Medical College and Sir JJ Group of hospitals, General Surgery, India, ²Government Medical College Nagpur, General Surgery, India

Background: Cystic lesions of spleen can include parasitic and non-parasitic types. Parasitic cysts account for 50-80% of the splenic cysts, with the major contributor being echinococcal disease. Splenic hydatid cyst is an extremely rare entity, with a worldwide incidence of 0.5-4%. Life threatening complications like anaphylaxis can present as an outcome of the silent disease process which can be easily missed out on radiological studies. Hence, hydatid disease of spleen should be considered as a differential in every patient in endemic areas of Mediterranean countries, Central Asia with cystic lesion of spleen until proven otherwise. Splenectomy has always been the conventional management and since 1980 treatment has evolved from splenectomy to spleen preserving techniques. The immunological superiority of the spleen demands novel approaches for preservation of spleen.

Method: At Grant Medical College, a total 55 cases of splenic cyst were operated involved both parasitic (40) and non-parasitic (15) lesion. In 47 cases spleen was conserved and 8 cases required total splenectomy. Out of 47 cases of spleen preserving surgeries performed 30 were parasitic and 17 non-parasitic. Patients were given Tab. Albendazole pre-operatively for 6 weeks. Spleen preservation with deroofing of cyst was done in all cases. 40 cases had solitary Splenic cyst (80%) and 10 cases had multiple splenic cyst (20%). The mean hospital stay was 7 days in uncomplicated cases and 14 days who required laparotomy.

Results: Out of 50 cases operated via endoscopic approach, 2 cases were converted to open surgery (5%) due to massive splenic hemorrhage from pedicle. Post operatively, 12 patients (24%) had significant post-operative pain of VAS more than 5 on average persisting for more than 24 h. While others had minimal post-op pain lasting for less than 6 h. During a follow up period of 36 months no recurrences were seen.

Conclusions: Splenic preservation is feasible, immunologically superior; with reduced pain, in hospital stay and early recovery of the patients. However meticulous dissection and careful addressal of tissue planes can reduce conversion rates.

SOLID ORGANS—Spleen

P199—SCOPE THE PARASITE: A Case series on Retroperitoneal hydatids managed laparoscopically

A. Bhandarwar¹, Amol Wagh ¹ , G. Girish¹, R. Gajbhiye², S. Jadhav¹, A. Tandur¹, S. Bhondve¹, N. Dhimole¹, K. Reddy¹, S. Dharmadhikari¹, G. Bharadwaj¹, H. Padekar¹, A. Dutt¹, B. Ganesan¹, R. Bhat¹

¹Grant Medical College and Sir JJ Group of Hospitals, General Surgery, India, ²Government Medical College Nagpur, General Surgery, India

Introduction: Retroperitoneal Hydatid cyst is exceptionally rare and only a small number of cases have been reported after Lockhart and Sapinza first reported a primary retroperitoneal Hydatid cyst. Hydatid cyst developed in retroperitoneal space without accompanied lesion in other organs is defined as primary retroperitoneal hydatid cyst. The annual incidence of cystic echinococcus is 220 per 100,000 inhabitants in the endemic areas like Mediterranean countries, Central Asia including the Tibetan Plateau, Northern and Eastern Africa, Australia, and South America.

Hematogenous dissemination is the most widely accepted hypothesis to explain the pathogenesis as the oncospheres in blood pass through the liver and lungs without seeding, and develop an implant in retro peritoneum.

With the worldwide incidence of just 1-3%, the paucity of cases and dearth in the reports of diagnosed ones makes this case a rare entity all together.

Method: At Grant Medical College, Mumbai, A total of 8 cases were operated for laparoscopic retroperitoneal Hydatid cyst and cystectomy was done in all the cases. On Computed tomography imaging all the patients had isolated retroperitoneal Hydatid cyst with no other primary lesions in Liver or lungs. Patients were given Tab. Albendazole (10 mg/kg/day) pre-operatively for 6 weeks for reducing the total parasitic load. The Laparoscopic ports were inserted through the flanks with adequate pneumoperitoneum created and total cystectomy was done in all cases without any spillage of contents.

The dissection was done via white line of toldt and laterally the cyst was dissected out first, further planes were created through all other sides and total enmass removal of the cyst was achieved.

Results: The mean operative time was 103.5 min and Average blood losses of 50 ml. Patients were discharged on POD 1 with Tab. Albendazole for 2 months post operatively (10 mg/kg/day). The mean hospital stay was 2 days. No recurrences were reported in a follow up period of 3 years.

Conclusion: Owing to the rarity of cases reported and no specified approach defined in the literature, it becomes extremely important to highlight this novel Laparoscopic approach for excision of retroperitoneal Hydatid cyst with combined medical therapy.

The overall approach has resulted in fewer recurrences than expected and hence medical therapy should be considered as an adjuvant with Minimal access surgeries.

UPPER GI—Benign Esophageal disorders

P200—Endoscopic Management of Broncho-Oesophageal Fistula Caused by Impacted Denture

Ahmed Elnabil-Mortada ¹

¹Ain Shams University—Faculty of Medicine/Sheffield Teaching Hospitals, Department of General Surgery, Egypt

Background: Dentures are common accidentally ingested among the elderly. Foreign body impaction at oesophagus in adults is common, but it is very unusual to have broncho-oesophageal fistula (BOF) caused by denture. Most of cases managed by thoracotomy, few reports described endoscopic management for other benign causes of (BOF).

Methods: We report a multidisciplinary management of a case of a broncho oesophageal fistula (image 1)caused by missed impacted denture.

Results: A 60-year-old male was transferred from DGH to our centre with history of swallowed denture 6 month earlier. Initial CT scan showed left broncho-oesophageal fistula. Multidisciplinary team management includes interventional radiologist, cardiothoracic, and upper gastrointestinal surgeons succeeded to manage this case by endoscopy without the need for thoracotomy. Endoscopic retrieval of impacted denture plate was successful, followed by insertion of left bronchial stent, and percutaneous gastrostomy tube. Left bronchial stent was removed after three months with successful closure of the fistula (image 2).

Conclusion: Multidisciplinary team discussion is crucial in management of complex surgical cases. Endoscopic management of broncho-oesophageal is an alternative option to thoracotomy in the big centre with available resources.

UPPER GI—Benign Esophageal disorders

P201—Esophageal Ruptures During Laparoscopic Upper GI Operations—Our Experience

Nikolaos Georgopoulos ¹ , N. Tasis¹, Chr. Barkolias¹

¹Athens Naval and Veterans Hospital, Surgical Department, Greece

Aim: Esophageal ruptures pose a rare but demanding clinical entity. The rupture may be spontaneous, traumatic or iatrogenic. Iatrogenic esophageal ruptures present usually during endoscopic procedures of the upper GI, yet, they may occur during upper GI operations as well. This poster presents the management and outcomes of five rare cases of iatrogenic esophageal ruptures during benign upper GI surgery in our department.

Methods: From 01.01.2004 tp 31.12.2020 129 laparoscopic Nissen procedures and 1105 bariatric operations [623 laparoscopic gastric bandings (LGB), 372 laparoscopic sleeve gastrectomies (LSG) and 110 laparoscopic RY gastric bypasses (LRYGB)] took place in our department. During the aforementioned period, five cases of intraoperative iatrogenic esophageal rupture were found. The cause of the rupture, the management and outcomes were analyzed.

Results: Out of the five cases, there were four females and one male with average age was 40.4 years old. Four cases concerned the abdominal segment of the esophagus while one the cervical segment. Abdominal esophageal rupture occurred during laparoscopic gastric band fixation and adjustment, during bougie insertion in a LSG, during nasogastric tube insertion into the gastric pouch in a LRYGB and during bougie insertion in a laparoscopic Nissen procedure. All abdominal esophageal ruptures were diagnosed intraoperatively and were primarily sutured. Cervical esophageal rupture occurred during bougie insertion in a laparoscopic Nissen procedure, it was diagnosed in the first postoperative day due to acute thoracic pain during liquid consumption and was managed successfully with surgery along with ENT department contribution.

Conclusion(s): Esophageal rupture during upper GI operations is an uncommon yet lethal complication. It raises the necessity for timely diagnosis and management. Its management may be surgical intraoperatively or early postoperatively.

UPPER GI—Benign Esophageal disorders

P202—Comparison Of Conservative And Mimimally Invasive Approaches To Treatment Of Patients With Esophageal Variceal Bleeding

Viktoriia Petrushenko ¹ , D. Grebeniuk¹, I. Radoga¹, V. Koval¹, M. Melnychuk¹, V. Stoika¹, V. Chubatiuk¹

¹National Pirogov Memorial Medical University, Vinnytsya, Department of Endoscopic and Cardiovascular Surgery, Ukraine

The aim of the study was to compare of the results of conservative and minimally invasive treatment of patients with esophageal varices bleeding.

Methods: The study included 281 patients with esophageal varices bleeding. Total number of men—159 (56.58%), women—122 (43.41%). The average age of patients was 58,1 ± 4,9 years. The source of bleeding was identified during endoscopy. All patients received drug therapy—non-selective beta-blockers, hemostatic, antisecretory, infusion, symptomatic. Patients of group 1 (n = 195) received just drug therapy. Patients of group 2 (n = 86) received minimally invasive endoscopic surgical interventions such as endoscopic band ligation of bleeding esophageal varices. Subsequently, to reduce portal hypertension the splenic artery embolization was performed to patients with high risk of rebleeding.

Results: The average age of patients in group 1 was 57.0 ± 4.3 years. Using just drug therapy we have stopped bleeding in 152 (77.95%) cases. In all cases at the end of treatment we received improvement of clinical and laboratory indices. 43 patients (22.05%) were died. Duration of treatment was 10.2 ± 2.1 days.

The average age of patients in group 2 was 58.1 ± 5.7 years. Performing of endoscopic band ligation we have stopped bleeding in 76 (88.37%) cases. In all cases at the end of treatment we received improvement of clinical and laboratory indices. 10 patients (11.63%) were died. Splenic artery embolization was performed to 35 (40.69%) patients. Duration of treatment was 6.7 ± 2.8 days.

Conclusion: Under the condition of esophageal varices bleeding treatment by performing the combination of endoscopic and endovascular treatment in comparison with only drug therapy we can see the improvement of patient’s condition, decreasing of mortality and duration of treatment.

UPPER GI—Esophageal cancer

P203—Surgical Outcomes Following Minimally Invasive Ivor Lewis Esophagectomy Do Not Ultimately Depend On The Anastomotic Technique

Francesco Puccetti ¹ , L. Cinelli¹, L. Manfrino¹, L. Barbieri¹, E. Treppiedi¹, A. Cossu¹, U. Elmore¹, R. Rosati¹,

¹IRCCS San Raffaele Hospital, Gastrointestinal Surgery, Italy

Aims: Ivor Lewis esophagectomy represents the most spread type of esophageal resection. Recent evidence has been increasingly supporting the diffusion and implementation of the minimally invasive technique for esophageal cancer surgery. However, a standardization of the minimally invasive esophagectomy has not been developed. The present study assesses three types of anastomosis techniques performed within a tertiary single-center experience.

Methods: This retrospective study analyzed a single-center series of consecutive patients submitted to minimally invasive Ivor Lewis esophagectomy from January 2015 to August 2021. Over this period, patients consecutively underwent three different types of anastomotic techniques: entirely linear-stapled Side-to-side (Group 3, 2015-2016), linear-stapled Side-to-side with handsewn closure (Group 2, 2016-2018), and circular-stapled End-to-side esophagogastric anastomosis (Group 1, 2018-nowadays). All linear-stapled Side-to-side techniques were also analyzed jointly as Group 4 and compared to Group 1. The primary endpoint was the occurrence of anastomotic complications, such as anastomotic fistula, conduit necrosis, and trachea-esophageal fistula. All clinical data were mined from an IRB-approved, prospectively maintained institutional database.

Results: A total of 293 patients underwent minimally invasive Ivor Lewis esophagectomy according to the above-mentioned anastomotic techniques: Group 1 (206 patients), Group2 (43), and Group 3 (44). The study population did not show statistically significant differences between groups' demographics, although longitudinal changes in management and surgical practice led to different median operative times, lymph node harvest, and proportions of patients being submitted to neoadjuvant therapy. Rates of severe anastomotic complications, either the anastomotic fistula or conduit necrosis, were not statistically different between groups, although tracheoesophageal fistula appeared to be significantly associated with Group 1. On the other hand, the anastomotic technique did not impact the overall postoperative morbidity, as well as the length of hospital stay and 30-day readmission. As a bias due to the establishment of the minimally invasive technique as our institutional gold standard for esophageal resections, increasing 90-day mortality was noted over time.

Conclusions: The technique of esophagogastric anastomosis cannot exclusively guarantee the goodness of final surgical outcomes. Other etiological causes should be sought among more relevant and comprehensive perioperative factors, such as stable hemodynamics over the earliest postoperative days.

UPPER GI—Esophageal cancer

P204—Anastomotic Leak Followed By Late Gastric Conduit Necrosis After Minimally Invasive Ivor-Lewis Esophagectomy: Clinical Case

Oleksii Dobrzhanskyi ¹ , Y. Kondratskyi¹, Y. Shudrak¹

¹National Cancer Institute, Upper Gastrointestinal Tumors Department, Ukraine

Introduction: Esophageal cancer remains highly aggressive neoplasm with poor prognosis. Treatment of esophageal cancer includes combination of surgery, radiation therapy and chemotherapy. However, surgical complications are critical after esophageal resections with high morbidity and mortality rate.

Aim: The main goal of the study is to describe a clinical case of late gastric conduit necrosis after minimally invasive Ivor-Lewis procedure.

Materials and Methods: A 72-year old men admitted to hospital for surgical treatment of local recurrence of squamous cell carcinoma. He received chemoradiation 1,5 years prior to admission and had radiological complete response. At the time of admission computed tomography showed a solid lesion on 33 cm of esophagus and 1 cm in diameter. Patient underwent minimally invasive Ivor-Lewis (laparoscopic and VATS) procedure with gastric tubular conduit formation. Indocyanine green (ICG) was applied to assess gastric conduit perfusion and it showed no violation in blood flow. Anastomotic leak was diagnosed on postoperative day 8. Patient was treated with local drainage and intraluminal stent placement. Patient was improving up to postoperative day 23 when gastric conduit necrosis with gastric wall perforation was diagnosed. Obstructive gastrectomy with cervical esophagostomy and feeding jejunostomy was performed. ICG was applied during surgery and no blood flow was observed in gastric conduit. However, patient got severe pleural empyema, lung abscesses, sepsis and thoracic wound infection. Patient received VAC-therapy on the thoracic wound. After infection processes was eliminated, patient underwent thoracic wound plastic with local tissues.

Results: The patient recovered on postoperative day 112 after primary esophageal resection. 104 days were spent in intensive care unit. Histological examination showed pT1aN0M0 R0 Lv0 Pn0.

Conclusion: Late gastric conduit necrosis is a rare complication after esophageal resection. Infectious complications are the background of prolonged hospital stay and high mortality rate. Indocyanine green may be used to assess intraoperative gastric conduit perfusion. However, prognostic value remains unclear.

UPPER GI—Esophageal cancer

P205—The Eso-SPONGE® Therapy for the Treatment of Anastomotic Leakage After Esophageal Surgery

Laura Fortuna ¹ , A. Bottari¹, F. Cianchi¹, F. Staderini²

¹AOU Careggi, Division of Digestive Surgery, Italy, ²AOU Careggi, Interventional Endoscopy, Department of Oncology and Robotic Surgery, Italy

Aim: anastomotic leakage after surgery for esophageal cancer represents a potentially lethal complication and it’s treatment remains challenging. Endoscopic debridement followed by the positioning of Eso-SPONGE® therapy can be an effective technique even for multiple, thoracic and mediastinal contaminations after dehiscence of intrathoracic esophagogastric anastomosis in appropriately selected patients.

Methods: we present two cases: a 61-years old woman with squamous esophageal cancer who underwent total robotic esophagectomy and a 65-years old man with esophageal adenocarcinoma treated with mini-invasive Ivor–Lewis esophagectomy.

On 12th and e 13th postoperative day respectively, both patients exhibited fever and dyspnoea, therefore a CT scan was conducted showing anastomotic leakage. The initial treatment with intravenous antibiotics was started but as clinical conditions failed to improve, they were referred for endovac therapy (EVT). The initial size of the wound was 1,5 × 2 cm and 4 × 2,5 cm, respectively. After the debridement and aspiration of corpuscular liquid, the Eso-SPONGE® was positioned. The device was replaced every 3-4 day in both patients.

Results: a complete recovery was achieved in both patients. The Eso-SPONGE® therapy was successful from the very first moments. The mean duration of EVT was 28 days, with 4 and 7 sessions respectively. Mortality was 0%. The mean follow up was six months showing no complication.

Conclusion: anastomotic leaks can have functional and oncological consequences. The treatment can also affect the general and oncological outcomes. Several strategies have been applied in its management and the Eso-SPONGE® has proven to be a minimally invasive method which offers excellent results especially in the treatment of the most fragile patients. This technique is well tolerated, feasible and effective and has shown the potential to significantly reduce morbidity and mortality. In both cases presented by us, further surgery was avoided.

UPPER GI—Esophageal cancer

P206—Esophagogastric Anastomosis with Invagination

O. Usenko¹, Georgiy Savenko ¹ , A. V. Sydiuk², O. E. Sydiuk³, A. S. Klimas¹

¹Shalimov’s National Institute of Surgery and Transplantation NAMS Ukraine, Department of Thoracoabdominal Surgery, Ukraine, ²Shalimov’s National Institute of Surgery and Transplantation NAMS Ukraine, Department of Intensive Care and Anaesthesiology, Ukraine, ³Shalimov’s National Institute of Surgery and Transplantation NAMS Ukraine, Department of Anesthesiology and Intensive Care, Ukraine

Introduction: At the present stage of the development of esophageal surgery in the leading healthcare institutions in the World, esophagectomy is routinely performed by minimally invasive technology. There is no significant difference in the safety of many types of minimally invasive esophagectomy compared with open esophagectomy. Esophagogastric anastomosis reconstruction is an unresolved issue. Anastomosis formation is a technically complex manipulation and it has a high risk of postoperative complications, such as anastomotic leak or stricture [1]. They lead to a decrease in quality of life and death. The rate of the anastomotic leak remains extremely high (5–10%) and the mortality rate can reach up to 30% [2; 3; 4; 5]. Stricture of the esophageal-gastric anastomosis in the world literature on average occurs in 42% of cases and ranges from 3 to 72%. A newly systematic review and meta-analysis of comparison of different anastomotic techniques (hand-sewn [HS], circular stapled [CS], triangulating stapled [TS], or linear stapled/semimechanical [LSSM] techniques) demonstrated advantages of LSSM and recommended using this technic as the preferred one. However, the optimum technique is still disputable [6].

We developed a new LSSM anastomosis with invagination, implemented it in routine practice. Up to day, we have applied it in 26 patients treated by minimally invasive esophagectomy for esophageal carcinoma and benign esophageal strictures. We have recently conducted a retrospective evaluation of the surgical safety and feasibility of our technique of esophagogastric anastomosis. Therefore, this article describes the procedure and results of our study.

Aim: In our article we are pleased to present a new method of forming the esophagogastric anastomosis. According to our experience and literature data, the use of different techniques for the formation of esophageal-gastric anastomosis does not give a statistically desirable result. High rates of anastomosis laek, stricture and mortality against the background of severe complications encourage further optimization of existing techniques and the development of new ones. The developed anastomosis should improve the postoperative results of esophagectomy, reduce the frequency of anastomosis laek and stricture due to the use of a linear suturing apparatus, and intussusception of the anastomosis into the lumen of the gastric graft.

Material and methods: 26 minimally invasive esophagostomies with invagination LSSM anastomosis were performed. In 20 patients (77%) of them, MIE was performed for esophageal carcinoma and six (23%) for benign esophageal diseases. In the study group, there were 21 (80%) men and 5 (20%) women. The average age was 53 (47–64) years.

There were 14 patients (70%) patients with squamous cell carcinoma and six (30%) patients with adenocarcinoma. There were 11 patients (55%) with localization in the middle third and nine (45%) patients with localization in the lower third. Neoadjuvant chemoradiation was performed in nine (45%) patients. The inclusion criteria were the following: non-metastatic disease, the absence of signs of tracheobronchial invasion, and the absence of end-stage disease (Table 1).

All of the oncological patients were examined in the preoperative stage according to NCCN (National Comprehensive Cancer Network) [7]. Physical laboratory examination, ECG, ultrasound of the heart, esophagogastroscopy, EUS, chest CT and esophagogastric X-ray was performed in patients with benign esophageal diseases. The inclusion criteria were the following: no concomitant pathology, which could be a contraindication to major surgery, clinically insignificant previous endoscopic treatment, persistent dysphagia stage III–IV.

All patients underwent minimally invasive Ivor Lewis esophagectomy (laparoscopy + VATS). All surgeries were performed by the same surgeon. The following intraoperative and postoperative data were evaluated: time of intervention, blood loss volume, postoperative length of stay, anastomosis scar stricture. In the postoperative period, patients underwent a survey, endoscopic monitoring for the presence of the anastomosis scar stricture after one, three, and six months and the manifestations of reflux esophagitis. Evaluation of dysphagia degree was performed according to the Bown scale [8; 9].

Method of anastomosis: A gastric isoperistaltic graft up to 4 cm wide is formed, which is supplied with blood through the right gastric, gastroepiploic, and intramural vessels. The graft is pulled up into the pleural cavity through the esophageal hiatus. Three seromuscular stitches are applied over 4 cm on both sides to the lateral surfaces of the esophagus posterior wall and gastric graft posterior wall, towards their edges, forming anastomosis “Side suture” (Figs. 1, 2). The formed sutures are tied so that the esophageal stump and the gastric graft are adjacent to each other for 4–5 cm with their posterior walls (Fig. 3).

The excess of the proximal part of the gastric graft is cut off at the level of the esophageal stump lumen. Two holding stitches are imposed on the distance of 1.5 cm from each other through all layers of the posterior wall of an anastomosis from the lumen (Fig. 4). Then holding stitches on a posterior wall are pulled up to place the linear stapler 30–40 mm deep (Fig. 5), stitch, and cut so that the posterior inner layer of sutures is formed (Fig. 6). The first layer of the anterior wall is sutured with a stapler (Fig. 7, 8). The next layer of sutures on the anastomosis anterior wall invaginates the esophageal stump into the gastric graft. Starting from the left edge of the anastomosis, the needle is inserted 2–2.5 cm from the inner layer capturing the seromuscular layer of the stomach and the adventitia with esophagus muscular layers. Normally 4–5 of such sutures are applied (Fig. 9). As a result, the esophagus is immersed in the gastric graft formed, up to 4–5 cm deep with no tension of the external sutures (Fig. 10).

The proposed method aims to form an invagination anastomosis with a depth of 30–40 mm. “Side suture” of the anastomosis applied to eliminate uneven immersion of the esophageal stump and strengthens the anastomosis. Holding stitches facilitate the stapler introduction. Due to the stapler use, a reliable three-layer line of the inner layer of the posterior and the anterior walls is swiftly formed. The invagination introduction allows the formation of a broad comparison of the esophageal adventitia and the stomach serous membrane. This provides greater reliability and tightness of the anastomosis, creates conditions for better healing, and prevents infection.

Extensive invagination anastomosis not only prevents anastomotic leak due to the wide area of comparison of the walls of the esophagus and stomach, but also reduces the likelihood of anastomotic stricture development due to edema or hypertrophic scarring, and has antireflux mechanisms that play an important role in reflux prevention.

To show the clinical effectiveness of the invagination semimechanical esophagogastric anastomosis, we present the following example.

UPPER GI—Esophageal cancer

P207—A Senior Surgical Resident Can Safely Perform Complex Esophageal Cancer Surgery After Surgical Mentoring Program—Experience of a European High-Volume Center

D. Müller¹, Benjamin Babic ¹, L. Schiffmann¹, T. Krones¹, J. Eckhoff², T. Schmidt¹, W. Schröder¹, C. Bruns¹, H. Fuchs¹

¹University of Cologne, Department for General, Visceral, Cancer and Transplant Surgery, Germany, ²Massachusetts General Hospital, Surgical AI & Innovation Laboratory, Department of Surgery, USA

Background: Previous studies have shown that if provided adequate training, patient selection and supervision residents can safely perform a variation of complex abdominal surgeries with equivalent outcomes compared to experience board certified surgeons. We have previously published a training curriculum for robotic assisted minimally invasive esophagectomy that may lead to a reduction in time to reach proficiency. However, while graduates from general surgery programs feel confident in their skills, training especially in esophageal surgery, which presents with a high postoperative morbidity up to 60%, is lacking. We aimed to investigate if a surgical resident could safely perform complex esophageal surgery when a structured modular teaching curriculum is applied.

Methods: Our prospectively collected, IRB approved database was searched to identify all Ivor-Lewis esophagectomies performed by the selected surgical resident from 08/2019-7/2021. Outcomes of patients where then compared to our overall cohort of open, hybrid and robotic Ivor-Lewis esophagectomies from 05/2016—05/2020. A structured teaching program based on our previously published modular step-up approach was applied by two experienced board-certified foregut surgeons.

Results: A total of 567 patients were analyzed. A total of 65 patients underwent an Ivor Lewis esophagectomy performed by the selected surgical resident. A total of 502 patients in the overall cohort underwent either an open, hybrid or robotic procedure. Demographic and oncological data is shown in Table 1. Mean age was 64.6 years (range 43-82) in the resident group and 63 years (range 33-91) in the overall cohort (p = 0.2433). Further details about postoperative complications are depicted in Table 2. No statistically significant difference was seen in sever postoperative complications defined as Clavien-Dindo ≥ IIIa (p = 0.2349)

Conclusion: A structured modulacr step-up for training a surgical resident to perform complex esophageal cancer surgery can successfully maintain patient safety and outcomes.

UPPER GI—Esophageal cancer

P208—Oesophageal Cancer: EUS Role Revisited

Nakul Gokhare Viswanath ¹ , A. Bohra¹

¹Royal Derby Hospital, Upper GI Surgery, United Kingdom

Oesophageal cancer is the 14th most common cancer in the United Kingdom. It accounts for about 5% of cancer related deaths in this country. The prognosis of oesophageal cancer is directly related to the stage of the disease when it is diagnosed, with better survival chances in patients who have it diagnosed it at an earlier stage. Computed tomography (CT) and Endoscopic ultrasound (EUS) are two important staging investigations for oesophageal cancer. The role of EUS in oesophageal cancers is to determine the locoregional staging and assessment of the local lymph node status. It also helps to direct therapy for early oesophageal cancers including submucosal dissection or mucosal resection. CT is routinely performed in all patients with oesophageal cancer for diagnosis and staging. It helps to pick up T2, T3 and T4 stage disease better than T1. Thus, performing EUS selectively in patients will help to avoid an additional investigation for the patient which may delay the institution of definitive treatment to oesophageal cancer patients. Bearing this in mind, we conducted an audit of all the patients who have had oesophageal cancer resections in our trust over the last 5 years. EUS was found to be more useful in patients who had tumour stage undefined on CT scan as opposed to T1 and above. This has directed a change in our cancer pathways to direct patients with higher stages to earlier treatment and avoided EUS in these patients.

UPPER GI—Esophageal cancer

P209—The Advantages Of The Cervical Ultrasound Examination During The Conservative Management Of Anastomotic Leakage After Hybrid Mckeown Esophagectomy

Călin Popa ¹ , D. Schlanger², C. Sofron², P. Puia², A. Ciocan³, S. Ursu², N. Al Hajjar²

¹"Iuliu Hatieganu "University of Medicine and Pharmacy/Regional Institute of Gastroenterology and Hepatology, Surgery, Romania, ²Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, Surgery, Romania, ³Institute of Oncology Bucharest, Surgery, Romania

Aims: The conservative treatment of anastomotic leakage from the cervical anastomosis after McKeown esophagectomy, is recognized as an efficient treatment option. Although, there is no standardized protocol recommended for conducting the conservative treatment of post-esophagectomy fistulas. Along with the conservative treatment, a careful monitorization is needed. We intend to emphasize through this study the advantages of the routine usage of seriate cervical ultrasound examinations during the conservative management program.

Methods: Our study is an observational pilot single-center prospective study, that includes patients that underwent hybrid McKeown esophagectomy (thoracoscopic approach), performed by the same surgical team, in the year 2021. Eighteen cases have been identified. All patients have been followed postoperatively by cervical ultrasound. For the patients that developed anastomotic fistula, a standardized management program has been implemented, that included a daily follow-up using seriate cervical ultrasound examinations.

Results: We have included 3 patients in our study, that developed cervical anastomotic leakage. The first two patients underwent a hybrid McKeown esophagectomy with reconstruction using the left colon, while the third patient underwent a hybrid McKeown esophagectomy with reconstruction using the gastric conduit. The patients developed the anastomotic fistula in postoperative days 6, 12 and 10, respectively. All patients followed the same standardized management protocol. The ultrasound examinations have been useful to monitor the dimensions of the perianastomotic collection (with its air and fluid components), and to view a day-to-day evolution that has not been apparent on clinico-biological parameters. We have been able to avoid unnecessary repetitive CT scans in all patients. The ultrasound evaluation has showed a favorable evolution in the first two patients, while in the third patient, the examination shifted the decision toward surgical intervention.

Conclusion: Conservative treatment of cervical anastomotic leakage is a feasible option, but careful monitorization of the patient is warranted in order to determine the best timing for further interventions, when needed. The first results of our pilot study show that cervical ultrasound is an easy-to-use, bedside examination that should added to the standard conservative treatment of anastomotic fistula is commenced.

UPPER GI—Esophageal cancer

P210—Real-Time Detection of Recurrent Laryngeal Nerves Using Artificial Intelligence in Thoracoscopic Esophagectomy

Kazuma Sato ¹ , D. Kajiyama¹, T. Akutsu¹, H. Matsuzaki², N. Takeshita², H. Fujiwara¹, K. Mori³, T. Fujita¹, H. Daiko¹

¹National Cancer Center Hospital East, Esophageal Surgery, Japan, ²National Cancer Center Hospital East, Surgical Device Innovation Office, Japan, ³Nagoya University, Graduate School of Informatics, Japan

Background: Because thoracic esophageal cancer has a high metastatic rate to the upper mediastinal lymph nodes, it is essential to perform complete lymphadenectomy around Recurrent laryngeal nerve (RLN) without complication, especially RLN paralysis (RLNP). It is important for surgeons to quickly and accurately identify the RLN during surgery, therefore intraoperative image navigation may be useful. The purpose of this study was to develop a deep learning model for RLN identification by semantic segmentation based on thoracoscopic videos, and clarify the accuracies of automatic RLN nerve identification.

Methods: Semantic segmentation of the RLN area was performed using a convolutional neural network(CNN)-based approach. DeepLab v3 plus was utilized as the CNN model for the semantic segmentation task. The Dice coefficient (DC) was utilized as an evaluation metric for the proposed model. We conducted the comparative study between Artificial Intelligence (AI) and surgeons (expert surgeons/general surgeon) to validate the accuracy of RLN identification.

Results: Three thousand RLN images were randomly extracted from 20 videos of thoracoscopic esophagectomy, and the RLN area was manually annotated on each image. The average DC for RLN in this AI model was 0.58. In the comparative study, the average DC were 0.58 for AI, 0.62 for expert surgeons and 0.47 for general surgeons. There was no significant difference in dice score for RLN between AI and expert surgeons(p = 0.38), but dice score in this AI model was significantly higher than it in general surgeons(p < 0.05).

Conclusions: This result suggest that AI may be useful in identifying the RLN during thoracoscopic esophagectomy. If the accuracy of AI is improved in the future, it may help safe surgery for thoracoscopic esophagectomy. Currently, we perform intraoperative real-time RLN identification using AI, and work to improve accuracy for clinical application(Figs. 1, 2).

UPPER GI—Gastric cancer

P211—The Learning Curve for Laparoscopic Subtotal Gastrectomy With D II Limphadenectomy. Results of a Pilot Randomized Controlled Clinical Trial

Estera Cristina Homorogan ¹ , E. C. Homorogan¹, S. Cuzmanov¹, D. A. Brebu¹, A. Isaic¹, L. Stoica¹, G. Noditi¹, G. Verdes¹, A. Dobrescu¹, V. Braicu¹, K. Botoca¹, G. Borcean¹, C. Tarta¹, F. O. Lazar¹, C. Duta¹

¹Spitalul Clinic Judetean de Urgenta Timisoara, 2nd General Surgery Clinic, Romania

Aim: We aim to define the learning curve for laparoscopic subtotal gastrectomy with D II limphadenectomy (LStG-DII) in an experienced laparoscopic surgical center and analyze the early results obtained by LStG-DII performed during the learning curve.

Methods: We designed a randomized active-controlled, single-center, hospital-based, two arms pilot study over a period of one year. The informed consent process was carried out for all patients with distal gastric cancer admitted to our clinic. Inclusion criteria were defined as: acceptance of informed consent process, distal gastric tumors clinically staged as T1, 2 or 3 and N0 or 1, with M0 and a maximum ASA risk of ASA III. Exclusion criteria were: refusal to accept the terms of the informed consent, previous abdominal surgery, advanced loco-regional or metastatic disease, patients classified as ASA IV or above. Patients were randomized using block randomization technique.

Results: We analyzed the intraoperative blood loss, surgery duration, intraoperative incidents, oncological radicality, number of limph nodes, mortality, morbidity and lenght of stay for the laparoscopic procedure and compared the results with those of the open procedure performed by the same surgeons after mastering the open surgery learning curve. 18 patients were included in this pilot study, nine for each treatment group. Statistical analysis was carried out using chi-square and Fisher’s exact tests and were considered significant if p < 0.05. Results showed that blood loss and duration of surgery were significantly higher for the laparoscopic group (p = 0.0149 and 0.0017 respectively). Postoperative mortality and morbidity were evaluated using the Clavien-Dindo classification and showed no overall significant differences, while open approach had a significantly higher percentage of grade I and II complications (p < 0.05). All the other variables analyzed showed no significant differences between the two groups.

Conclusions: Although in the initial stages of the learning curve, results showed that LStG-DII is a feasible and safe procedure, when compared to the better established open approach, requiring the mastering of the learning curve in order to eliminate the significant differences.

UPPER GI—Gastric cancer

P212—Impact of Diagnostic Laparoscopy in the Management of Gastric Cancer in Egyptian Patient

Mostafa Refaie Abdelatty Elkeleny ¹ , M. EL Rewini¹, M. Sorour², K. Ahmed²

¹Faculty of Medicine,Alexandria University, General Surgery Department, GIT Unit, Egypt, ²Alexandria University, General surgery department, Egypt

Background Gastric cancer (GC) is one of the leading causes of cancer-related deaths. In Egypt, it is the 14th among cancers mortality. Preoperative imaging as Computed Tomography and Endoscopic Ultrasonography have limitations in predicting the advanced disease, leading to many unnecessary laparotomies with more morbidity and mortality. Therefore, diagnostic laparoscopy (DL) may play a vital role in preoperative staging.

The aim of the work was to evaluate the role of diagnostic laparoscopy (DL) in detecting peritoneal, liver metastasis and malignant ascites. Methods 40 patients of GC were involved, preoperative abdomen CT scan was done. DL was done under general anaesthesia through 3 ports, the liver and whole peritoneal surfaces were examined for any metastasis, also any ascites was aspirated if there was no ascites irrigation with saline was done and re-aspirated. Any metastasis was biopsied and examined by frozen section also any aspirate was undergoing immediate cytological examination.

Results DL was positive in 12 patients (30%), detected as the following: 6 patients with liver deposits, 4 patients with peritoneal deposits and 2 patients with positive cytology. Therefore these 12 patients avoided unnecessary laparotomy, while the remaining 28 patients underwent curative resection of the tumor.

Conclusion About 30% of GC is advanced once diagnosed. DL may be very helpful in detecting metastatic tumor missed by CT scan. Liver metastasis is the commonest metastasis of GC. Patients with positive DL avoid unnecessary laparotomy, and this does not delay them of having palliative treatment

UPPER GI—Gastric cancer

P213—Many Ways to Skin Gastric Cancer"—Robotic versus Laparoscopic versus Open Gastrectomy

Eli Kakiashvili ¹

¹Galilee Medical Center, General Surgery, Israel

Aim: robotic techniques relevance in gastric cancer surgery is being examined. The study presents comparison of perioperative outcome between different surgical approaches for gastric adenocarcinoma (AC).

Methods: retrospective cohort of 85 patients that underwent gastrectomy for (AC) at Rambam Hospital during 2012-2016. Patients data was collected based on demographic characteristics, BMI, operating room time (ORT), number of lymph nodes (LN), length of hospitalization (LOH), and perioperative complications.

Results: study population included 55 patients after total gastrectomies, 10 of them robotic and 30 partial gastrectomies, 12 of them robotic. Age, gender and BMI were similar between patients who underwent any type of procedures.

Median length of hospitalization (LOH) for robotic total gastrectomy was 4.5 days and it was significantly shorter than both laparoscopic total gastrectomy (LTG) 7.0 days (p = 0.003) and open total gastrectomy (OTG) 9.0 days (p < 0.001). Similar significant differences in (LOH) between the groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of (LPG).

Median(ORT) was significantly longer among robotic gastrectomies compared to open, the difference was 64 min in total gastrectomy group and 145 min in partial gastrectomy group (p < 0.001 for both differences), but the difference in(ORT) between laparoscopic and robotic procedures were smaller and non-significant.

The number of dissected (LN) was similar between the 3 procedures in total gasrectomies. In partial gastrectomies, the number of dissected (LN) was even higher among both laparoscopic and robotic gastrectomies compared to open (p < 0.001).)

Conclusions: robotic total and partial gastrectomies for gastric (AC) are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer ORT.

UPPER GI—Gastric cancer

P214—Short term clinical outcome of totally laparoscopic middle segmental gastrectomy

Sang Soo Eom ¹ , Y. W. Kim¹, S. H. Park¹, F. Merei¹

¹National Cancer Center, Department of Surgery, Korea

Objective: Totally laparoscopic middle segmental gastrectomy (TLMSG) is developed as a function-preserving surgery for the proper indication we published recently. Purpose of this analysis is to show the short the term clinical outcome comparing with totally laparoscopic distal gastrectomy (TLDG).

Method: For case control study, we retrospectively reviewed the clinicopathological data of 27 patients who underwent TLMSG and 148 patients who underwent TLDG with Billroth I anastomosis for early gastric cancer between 2018 and 2019 at National Cancer Center, Korea. Nutritional status including postoperative serum hemoglobin, total protein, albumin, body weight change), postoperative endoscopic findings, complications were compared between the two groups.

Results: There was no difference in demographic features between the two groups. Decrease of serum hemoglobin level was significantly lower in the TLMSG group than in the TLDG group (P = 0.031). Other nutritional status variables were not different. In the endoscopic findings, incidence of residual food was significantly higher in the TLMSG group than in the TLDG group (P = 0.019). bile reflux and esophagitis findings in endoscopy were not significantly different. Postoperative complications were not significantly different. Operative time, estimated blood loss and hospital stay were not different. Significantly a greater number of lymph nodes was harvested for TLDG (35.6 ± 12.3 vs. 30.0 ± 10.2, p = 0.013). Resection margins were significantly shorter for TLMSG (proximal: 91.6 ± 1.1 cm vs. 4.6 ± 2.7 cm, distal: 2.7 ± 2.4 cm vs. 6.4 ± 3.0 cm, p < 0.001 respectively).

Conclusion: TLMSG might be a good surgical option for the proper indication. Long term outcome and further prospective clinical study is needed to confirm its role.

UPPER GI—Gastric cancer

P215—M6A Methylation Mediates LHPP Acetylation As A Tumour Aerobic Glycolysis: Suppressor To improve The Prognosis of Gastric Cancer

Hua-Gen Wang ¹, L. P. Zhuang¹, K. Weng², N. Z. Lian¹

¹Fujian Medical University Uion Hospital, Gastric Surgery, China, ²Fujian Medical University Uion Hospital, Neurology, China

Background: LHPP, a histidine phosphatase, has been implicated in tumor progression. However, its role, underlying mechanisms, and prognostic significance in human gastric cancer (GC) are elusive.

Methods: We obtained GC tissues and corresponding normal tissues from 8 patients and identified LHPP as a downregulated gene via RNA-seq. qRT-PCR and western blotting were applied to examine LHPP levels in normal and GC tissues. The prognostic value of LHPP was elucidated using tissue microarray and IHC analyses in two independent GC cohorts. The functional roles and mechanistic insights of LHPP in GC growth and metastasis were evaluated in vitro and in vivo.

Results: LHPP expression was significantly decreased in GC tissues at both the mRNA and protein level. Multivariate Cox regression analysis revealed that LHPP was an independent prognostic factor and effective predictor in patients with GC. The low expression of LHPP was significantly related to the poor prognosis and chemotherapy sensitivity of gastric cancer patients. Moreover, elevated LHPP expression effectively suppressed GC growth and metastasis in vitro and in vivo. Mechanistically, the m6A modification of LHPP mRNA by METTL14 represses its expression; LHPP inhibits the phosphorylation of GSK3b through acetylation, and mediates HIF1A to inhibit glycolysis, proliferation, invasion and metastasis of gastric cancer cells.

Conclusions: LHPP is regulated by m6A methylation and regulates the metabolism of GC by changing the acetylation level. Thus, LHPP is a potential predictive biomarker and therapeutic target for GC.

UPPER GI—Gastroduodenal diseases

P216—Different Clinical Presentation of Jejunal Diverticulitis: Report of Two Cases

Giovanni Cestaro ¹, F. Cavallo², A. Azabdaftari², L. Fogato²

¹ASST Valle Olona—Gallarate Hospital, General Surgery, Italy, ²AULSS 5 Polesana—Adria Hospital, General Surgery, Italy

Background: Small bowel diverticulosis is a rare clinical finding and its complication, such as diverticulitis, can represent a diagnostic challenge that have various clinical patterns. Hereby we present two cases we treated at our Surgical Department (UOC Chirurgia Generale—ULSS5 POLESANA-Adria).

Cases Report: We report two surgical cases: a male adult patient (62 years old) and a female old patient (94 years old) presented at our department with two different surgical patterns, i.e. bowel perforation and bowel obstruction. After emergency explorative laparotomy, we did diagnosis of jejunal diverticulitis and we performed bowel resection and manual anastomosis in both cases, following by uneventful postoperative course and discharge.

Discussion: Jejuno-ileal diverticulosis is uncommon and it was firstly described by Somerling in 1794. Most cases are asymptomatic, incidentally diagnosed during a laparoscopy/laparotomy and they are related to an abnormal neuromotor innervation that leads to dyskinesia and diverticula formation usually on the mesenteric side.

Conclusion: Emergency laparoscopy/laparotomy and affected bowel resection are mandatory to treat this challenging and rare pathological condition with efficacy and safety 13. We treated two cases in 8 months, both patients had radiological findings not suggestive of jejuno-ileal diverticulitis.

UPPER GI—Gastroduodenal Diseases

P217—Surgical and Oncological Outcomes of Large Gastrointestinal Stromal Tumors Treated by Laparoscopic Resection

Sheng Chieh Lin ¹ , H. H. Yen¹, P. C. Lee¹, I. R. Lai¹

¹National Taiwan University Hospital, Department of Surgery, Taiwan

Background. The resection of large gastric gastrointestinal stromal tumors (GISTs) by laparoscopy has been controversial. This study reported the long-term oncological outcome of laparoscopic resection of large (5-8 cm) gastric GISTs in a single center.

Methods: From 2002 to 2018, a consecutive 66 patients with gastric GISTs of 5-8 cm were treated at National Taiwan University Hospital. Among them, 30 patients received open surgery, and 36 received laparoscopic surgery. The clinicopathological data, peri-operative and oncological outcomes were compared between groups.

Results: The clinical demographics including sex, age, BMI, tumor size, tumor locations and ratio of wedge resection were similar between groups. The operation time, blood loss, and post-operative complications, were also similar between groups. The mean hospital stay was shorter in the laparoscopic group (8.8 ± 2.5 days) than in the open group (12.0 ± 8.9 days), though not significantly different. The median follow-up time was 108 ± 58 months (97 ± 50 in laparoscopic group; 122 ± 64 in open group). All except three patients remain disease-free. One in the open group and two in the laparoscopic group had recurrence of tumor, and they were stable of disease under Imatinib treatment. Eight patients died in non-GIST causes during follow-up.

Conclusion: Our data showed that laparoscopic surgery for gastric GIST between 5-8 cm was safe and oncologically-feasible.

UPPER GI—Gastroduodenal diseases

P218—The Impact of Local PRP Injection on the Gastric Mucosa Lipid Peroxidation in Rats with Peptic Ulcers and Hemorrhagic Shock

Viktoriia Petrushenko ¹ , D. Grebeniuk¹, I. Taran², V. Sobko¹, N. Liakhovchenko¹

¹National Pirogov Memorial Medical University, Vinnytsya, Department of Endoscopic and Cardiovascular Surgery, Ukraine, ²National Pirogov Memorial Medical University, Vinnytsya, Department of Pharmacology, Ukraine

The aim of the study was to evaluate changes in gastric mucosa Malondialdehyde (MDA) after local PRP injection in rats with peptic ulcers and hemorrhagic shock in experiment.

Methods: The study was performed on 91 Wistar rats (average weight of animals was 183 ± 16 g) according to local and international rules for working with experimental animals. We randomly divide all animals in 5 groups: Control Group (n = 7)—intact animals; Comparison Group (n = 21)—gastric ulcer; Group 1 (n = 21)—gastric ulcer + hemorrhagic shock; Group 2 (n = 21)—gastric ulcer + hemorrhagic shock + local injection of 0.1 ml of 0,9% sodium chloride; Group 3 (n = 21)—gastric ulcer + hemorrhagic shock + local injection of 0.1 ml platelet-rich plasma (PRP).

Peptic ulcers were modeled using our modification of type 2 acetic acid ulcer model (Susumu Okabe, 2005). Hemorrhagic shock was modeled by 3–3.5 ml blood sampling. On 1st, 7th and 14th day measurement of mucosal MDA levels were performed.

Results: In all groups and on all control days of the study, MDA activity levels were higher than in the control group.

On day 1, MDA activity in Groups 1, 2, 3 were significantly higher (p < 0.05) than in the Comparison Group. Moreover, the indices in the Groups 1, 2, 3 didn’t significantly differ from each other (p > 0.05).

On day 7 of the study, we didn’t reveal a significant difference in the level of the studied indicator between the Comparison Group and Group 3 (p < 0.05), as well as between Groups 1 and 2 (p > 0.05). Moreover, in pairwise statistical comparison, the indicators in the Comparison Group and Group 3 were statistically significantly lower than the similar levels in Groups 1 and 2 (p < 0.05).

On the day 14, there were no differences between MDA levels in Comparison Group and Groups 1 and 2. In the same time MDA levels in Group 3 were significantly lower than levels in all other groups (p < 0.05) and approached the indices of the control group.

Conclusions: Hemorrhagic shock is accompanied by an intensification of lipid peroxidation in the gastric mucosa. Local PRP injection in rats with peptic ulcers and hemorrhagic shock allows to inhibit lipid peroxidation in the periulcelar zone.

UPPER GI—Gastroduodenal Diseases

P219—Idiopathic Spontaneous Pneumoperitoneum In A Healthy Adolescent.

Shu Ying Chee, ¹ , M. Megally¹, A. Hamour¹, M. Khanzada¹, M. Aremu¹

¹Connolly Hospital Blanchardstown, General Surgery, Ireland

Introduction: Pneumoperitoneum is most often caused by a perforation of a hollow viscus and is often considered a surgical emergency. However, idiopathic spontaneous pneumoperitoneum is a rare condition that is characterized by intraperitoneal gas without gastrointestinal tract perforation, for which there is no clear identification of any etiology.

Methods: We describe a case of an 18-year-old female who presented to the emergency department with left shoulder tip pain and upper abdominal discomfort. On examination, her abdomen was soft and non-tender. She had an erect chest X-ray which showed air under the diaphragm indicative of a pneumoperitoneum. Subsequently, she had a CT abdomen pelvis which demonstrated pneumoperitoneum but the source could not be identified on imaging. She also had an OGD which was normal.

Results: She was well and vitally stable throughout her admission. She was monitored for 48 h in hospital and was subsequently discharged home. She was followed up in our outpatient clinic two weeks after discharge and remained clinically well. Her repeat erect chest X-ray at the 2 weeks outpatient clinic visit showed complete resolution of her pneumoperitoneum.

Conclusion: A detailed medical history, physical examination, appropriate laboratory tests and radiological investigations are valuable tools to identify patients with non-surgical pneumoperitoneum. Knowledge of this rare disease will help in avoiding unnecessary laparotomy.

UPPER GI—Gastroduodenal diseases

P220—Endovideosurgical technology in the treatment of perforated gastroduodenal ulcers

Aleksandr Ukhanov, ¹ , D. Zakharov¹, S. Bolshakov¹, S. Zhilin¹, A. Leonov¹, K. Muminov¹, J. Aselderov¹

¹Central Municipal Clinical Hospital, Surgical, Russia

The Aim: Improving of the results of operative treatment of the patients with perforated gastroduodenal ulcers due to expansion of indication for endovideosurgical technology.

Material and Methods: 416 patients with perforated ulcers of stomach and duodenum were operated on from 2013 till 2021 years. Age of the patients varied from 18 till 78 years. Laparoscopic treatment with Z-suturing of perforated hole and bubble test was carried out in 152 cases (36,5%). 264 patients were operated on by laparotomy.

Results: Conversion rate was 3,3% (5 from 152 cases). One patient was operated on again a few hours after initial operation due to duodenal sutures leakage. Relaparoscopy and additional suturing was carried out with good result. Postoperative morbidity was 5,3% (8 cases). One patient after laparoscopic treatment died (0,7%), while in the group with open treatment of perforated ulcer postoperative mortality was 7,2% (19 patients from 264 died).

Conclusion: Expansion of indication for endovideosurgical technology has definite advantages over open methods in the surgical treatment of perforated gastroduodenal ulcer and, in the absence of contraindication should more widely applied in the urgent surgery departments.

UPPER GI—Reflux-Achalasia

P221—Mesh reinforcement of hiatoplasty for large hiatal hernias

Vasile Bintintan ¹ ,

¹University of Medicine and Pharmacy Cluj Napoca, Chirurgie, Romania

Introduction: Simple closure of the hernia defect in large hiatal hernias is associated with high risk of recurrence and the prospect of a second operation. Reinforcement of the hiatoplasty with a mesh reduces these risks but is associated with other inconveniences.

Materials and methods: We routinely reinforce the hiatoplasty with a U shaped dual mesh prosthesis placed around the esophagus and fixed centrally to the diaphragmatic pillars and in the periphery to the diaphragm if the diameter of the hernia exceedes 5 cm or if the hiatoplasty is under tension. A Nissen or Toupet fundoplication is used according to the anatomical and functional status of the esophgus and gastric fundus. The technique is discussed in a presentation video.

Results: The first 25 patients operated with this technique were included in a prospective study. The mesh was anchored in all cases either using a combination of EndoHernia 120 clips and sutures or sutures alone. In one early case, postoperative cardiac tamponade occured 24 h after surgery due to injury from an incompletly closed clip. No other intraoperative or early postoperative incidens were encontered. There were no complications related to mesh migration. There was no recurrence of the hernia, no disphagia beyond 6 months postoperatively and the reflux score improved significantly in all patients.

Conclusions. With meticulous technique, mesh reinforcement of the hiatoplasty is a safe procedure in experienced hands and reduces the the long-term risk of recurrence.

UPPER GI—Reflux-Achalasia

P222—Robot-Assisted and Laparoscopic Surgery in Patients with Giant Hiatal Hernias

R. Komarov¹, Sergey Osminin ¹ , S. Osminin¹, F. Vetshev², A. Egorov¹, I. Bilyalov¹

¹FSAEI of HE I.M. Sechenov First MSMU of the Ministry of Health of the Russian Federation, Department of Faculty Surgery №1, Russia, ²FSAEI of HE I.M. Sechenov First MSMU of the Ministry of Health of the Russian Federation, Department of Oncology, Radiology and Reconstruction Surgery, Russia

Aim. To compare the short-term outcomes of robot-assisted fundoplication (RAF) and laparoscopic fundoplication (LF) in patients with giant (type III) hiatal hernias (HH).

Methods: Data for 64 patients who underwent robot-assisted or laparoscopic fundoplication for type III of HH at our hospital between January 2015 and February 2021 were retrospectively analyzed. The selection included 32 patients who underwent RAF and 32 patients—treated laparoscopically. There were no significant differences between the laparoscopic and the robotic groups in terms of age, sex, BMI, comorbidities. Short-term outcome measures such as mean operation time, blood loss, duration of hospital stay, and postoperative complications were analyzed.

Results: Operation time was shorter in the RAF group (125 ± 6,6 min versus 153,2 ± 8 min; p = 0,009). Mean blood loss was similar in the two groups (RAF—19 ± 2 ml; LF—23 ± 3,2 ml; p = 0,264). The rate of postoperative complications in the RAF group and LF group were 9% (Clavien—Dindo I-IIIa) and 15% (Clavien—Dindo I-IIIb) respectively (p = 0,450). Our results showed that the robot-assisted fundoplication was associated with a shorter hospital stay (7,8 ± 0,38 days versus 9,7 ± 0,49 days; p = 0,003). There were no conversions in the two groups.

Conclusion: Safety and short-term efficacy seem comparable between RAF and LF in patients with giant (type III) of hiatal hernias. The robot-assisted fundoplication was associated with a shorter operation time and hospital stay.

UPPER GI—Reflux-Achalasia

P223—Modern Achalasia-A New Perspective on a Long-Standing Disease

Gad Marom ¹ , R. Brodie¹, H. Al Haroob¹, L. Luques¹, Y. Fishman¹, H. Jacobs², A. Benson², J. Epstein², H. Hershkovitz², Y. Mintz¹

¹Hadassah Ein Kerem, General Surgery, Israel, ²Hadassah Ein Kerem, Department of Gastroenterology, Israel

Introduction: Achalasia patients typically suffer from progressive dysphagia, vomiting and significant weight loss. The Eckardt score, used to evaluate the severity of the disease, is question based, and includes dysphagia occurrence and weight loss. However, in the last two decades the global obesity pandemic has changed the appearance of achalasia patients. Weight loss and dysphagia are no longer the hallmarks of the disease.

Our aim was to describe the new entity of modern achalasia and evaluate if overweight and obese patients have a different objective pre-operative evaluation as well as post-operative outcome.

Methods: A retrospective study on a prospectively maintained database was performed on all patients treated for achalasia in our institution from 2012 to 2020. Pre-operative weight loss, pre- and post-operative IRP levels, length of stay (LOS), operative time and post-operative complications were studied.

Results: One hundred twenty-six patients were included in the study. 77 patients (61%) had a BMI of 25 or less and consisted the normal weight group (NW). 49 patients (39%) were overweight and obese (OWAO group). The 2 groups had similar male to female ratio and type of achalasia. Both groups had a similar pre- and post-op IRP, operative time, LOS. However, the pre-op weight loss was considerably lower in the OWAO group, the pre-op Eckardt score was higher in the NW group than in the OWAO group as well as the its’ change post-op. in addition, the pre-op dysphagia was lower in the OWAO group than in the NW group.

Conclusions: As high-resolution manometry becomes more available and improved awareness of clinicians of this rare disease, the incidence of achalasia diagnosis increases. Surgical myotomy is safe and gives equal clinical outcomes in the overweight and obese population. Typical appearance of cachexia and vomiting are no longer valid due to the obesity pandemic. Dysphagia and weight loss are less pronounced due to the accessibility of soft food and high protein shakes. evaluation of severity using the Eckardt score has limited value in today’s era. New objective measures for assessing the severity of achalasia are needed.

UPPER GI—Reflux-Achalasia

P224—Long-Term Outcomes of Patient Satisfaction After Laparoscopic Nissen Fundoplication

Natalia Dowgiałło-Gornowicz, P.L. Lech

¹University of Warmia and Mazury in Olsztyn, Department of General, Minimally Invasive and Elderly Surgery, Poland

Aim: Up to 33% of population suffers from gastroesophageal reflux disease (GERD), which has negative impact on quality of life. This study aims to assess long-term patient satisfaction after laparoscopic Nissen fundoplication (LNF).

Methods: We reviewed the prospectively collected data of patients who underwent LNF for GERD in Department of General, Minimally Invasive and Elderly Surgery in Olsztyn in 2014–2018. Postoperative survey consisted two “yes or no” questions to assess satisfaction with the outcome.

Results: 111 patients (49 female, 62 male) were analyzed in the study. All patients underwent LNF in 2014–2018 by the same team of surgeons. The mean age was 50.2 years (18–80 years, ± 15 years) and the mean body mass index was 25.9 kg/m2 (17.7–35.6 kg/m2 ± 3.5 kg/m2). Tthe means follow-up time was 50 months (21.2–76.3 ± 16.6 months).

The first question was if the patients recommend LNF to their relatives.. 87 of them (78.4%) would recommend surgery. The second question was whether, with the knowledge they have now, they would undergo surgery again. 17 patients (15.3%) would not undergo LNF again. Patients without recurrence of symptoms and without the need for chronic PPIs use after surgery were significantly more likely to undergo the surgery again or recommend surgery to their relatives (p < 001). All 17 patients who would not recommend LNF to their relatives or undergo LNF again were identified as dissatisfied and asked for their rationale. Two of them, after early stenosis, were not satisfied with the need for reoperation. 12 had recurrence of symptoms or needed PPIs and did not think about the surgery as a cure. Three patients, despite their symptom relief, would not wish to undergo perioperative stress again.

Conclusion: LNF is a good treatment for GERD with a satisfaction rate of 78.4%.

UPPER GI—Reflux-Achalasia

P225—Redo-surgery After Failed Anti-reflux Procedures. A Single Centre Experience

Graziano Ceccarelli ¹ , M. Valeri², L. Amato², L. Trentavizi¹, F. Arteritano¹, M. De Rosa¹, W. Bugiantella¹, F. Rondelli³

¹San Giovanni Battista Hospital, General Surgery, Italy, ²University of Perugia, General Surgery, Italy, ³Santa Maria Hospital—University of Terni, General Surgery, Italy.

Introduction: Minimally invasive Nissen fundoplication is the most common procedure for gastroesophageal reflux disease (GERD) with or without associated hiatal hernia, presenting a failure rate of approximately 20% on long-term follow up. The most frequent failure causes are: persistent post-operative dysphagia (one in three patients), gas bloat syndrome, persistent-recurrent reflux symptoms and other complications. A part of these patients may be candidated to a redo anti-reflux surgery. This surgery may be may be performed using a minimally invasive approach too, but is technically challenging for the high rate of severe complications. Furthermore the best technique for redo surgery remains debatable: re-fundoplication, gastric bypass or gastric resection and others procedures.

Methods: We reviewed our last 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary and 11 (3.4%) for revisional surgery. The revisional surgery (RS) serie included 7 females and 4 males, a mean age of 57.6 years (43–71), a BMI > 30 in 4 cases. In all the cases the previous surgery was a Nissen fundoplication. The average time from the primary surgery was of 42 months (7–108). The causes of post-operative failure were: stomach hernation, wrap deishence, valve telescoping, a too narrow wrap and upside down stomach. All procedures were performed by two surgeons expert in laaproscopy and in robotic surgery. Pre-operative investigations included endoscopy, esophageal pH /manometry study, esophago-gastric junction X-ray contrast study and in selected cases abdominal and chest CT scan (all cases for hiatal hernias).

Results: All procedures were performed using a minimally invasive (10 using the robotic technique), no conversion to open surgery was registered.. The types of redo-surgery were: 9 redo-fundoplication (4 Nissen and 5 Toupet, 2 Roux-en-Y short-limb gastric by-pass), a hiatoplasty was performed in 8 cases and an absorbable mesh was used in 5 cases. One case was performed in emergency setting. Mean operative time was 147 min and mean hospital stay was 3.2 days (2–7). No Clavien-Dindo grade 3–4 were observed. One persistend post-operative dysphagia was registered in the follow-up.

Conclusions: Redo antireflux surgery is indicated in selected patients. Minimally invasive surgery, both through laparoscopy or robotic approach, is feasible. Representing a challenging surgery if compared to primary surgery, it has to be performed in specialised centres. Robotic technology may represent a valid option to overcome any technical difficulties.

UPPER GI—Reflux-Achalasia

P226—Correction of Obstruction of the Upper Digestive Tract Using Balloon Dilation

Oleksandr Babii, B.F. Shevchenko, N.V. Prolom, S.O. Tarabarov

¹SI “Institute of Gastroenterology of NAMS of Ukraine”, Department of Surgery of Digestive Tract, Ukraine

Objectives. In recent years, balloon dilatation (BD) for diseases requiring correction of the impaired patency of the upper digestive tract has become widespread.

Purpose: to assess the effectiveness of the use of the balloon dilatation in patients with impaired of the upper digestive tract.

Materials and Methods: In the Institute department of surgery for the period from 2006 to 2021, BD was performed in 330 patients. 227 of them diagnosed with achalasia of cardia (AC): 21—1 stage, 92—2 stage, 68—3 stage, 46—4 stage. 11 patients diagnosed with pylorospasm, 35 patients had compensated stenosis and 57 patients had subcompensated ulcerative pyloroduodenal stenosis. There were 106 males, 224 females, average age (45.6 ± 5.4).

BD was performed under endoscopic and/or x-ray control by “Boston Scientific” balloons with a diameter of 18–20 mm, 35 mm and 40 mm, a course of 3–6 sessions with an interval of 1–3 days and a cylinder exposure of 3–6 min. Evaluation of BD was performed using esophagogastroscopy, balloon manometry and X-ray passage of barium.

Results: In the course of the study, the existing indications were refined and new indications were developed for performing an endoscopic BD in pyloroduodenal stenosis and in AC.

In patients with stage 1–2 AC, a positive result was noted in 94.6% of cases already after the first session of BD. Recurrences of AC after BD for up to 5 years were established in 53 (24.2%) patients: at stage 1—in 9.5%, at stage 2—in 16.3%, at stage 3—in 23.5% and at stage 4—in 47.8%. Repeated BD courses in case of AC recurrence in 29 (13.8%) cases turned out to be ineffective.

Recurrence of pyloroduodenal subcompensated stenosis was diagnosed in 2.9% of cases in the period of 4 years after performing BD.

Conclusions. BD is an effective method for correcting the permeability of the upper digestive tract caused by the pathology of the esophagogastroduodenal region.

Keywords: balloon dilatation, achalasia of cardia, pylorospasm, ulcerative pyloroduodenal stenosis, recurrences.

UPPER GI—Reflux-Achalasia

P227—Complex Surgical Treatment of Oesophageal Achalasia in the Era of Minimally Invasive Surgery: Short- and Long-term Results

László Andrási ¹ , A. Paszt¹, Z. Simonka¹, S. Ábrahám¹, M. Erdős¹, A. Rosztóczy², G. Ollé², G. Lázár¹

¹University of Szeged, Department of Surgery, Hungary, ²University of Szeged, 1st Department of Internal Medicine, Hungary

Aims: We have analysed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative oesophageal function.

Methods: Between 2008 and 2020, 69 patients with oesophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Sixy-three of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an oesophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic oesophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and postoperative complaints were evaluated.

Results: No intraoperative complications were observed, and no mortalities resulted. During the 12–24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 40%; diffuse oesophageal spasm: 60%), while its occurrence in the TI type did not change significantly (12.1%—9.7%). As a result of the follow-up of more than two years, good symptom control was achieved in 95.1% of the patients, with only three patients (4.7%) developing postoperative reflux.

Conclusions: The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.

UPPER GI—Reflux-Achalasia

P228—Prevention of Mesh-related Complications During Hiatal Hernia Repair

Viktor Grubnyk ¹ , V.V. Grubnik¹, M.R. Paranyak², V.V. Ilyashenko¹

¹Odessa National Medical University, Surgery, Ukraine, ²Danylo Halytsky Lviv National Medical University, General Surgery, Ukraine

The use of mesh implants for hiatal hernia repair can reduce the recurrence rate. At the same time, non-absorbable synthetic polypropylene and polytetrafluoroethylene mesh implants can cause erosion and migration into the lumen of esophagus and stomach. Management of these complications is difficult and may require redo surgery with increased risk of mortality and morbidity.

Purpose. To evaluate the effectiveness of surgical maneuvers during hiatal hernia repair to reduce the risk of mesh-related complications.

Methods: For the period from 2010 to present time in our clinic were used special methods to prevent mesh-related complications. Usually, we use small pieces (4.5 -6.5 cm.) of mesh with U-shape configuration. The experience of our clinic has shown that this configuration and size of the implant can reduce the number of complications associated with the mesh. For fixation of mesh, we used sutures, tackers. If possible, the self-fixating ProGrip mesh was used. The surgical maneuvers were as follows:

Firstly, we mobilize left lobe of liver to make the fixation of mesh easier. In patients with giant hernias, we don’t install the mesh between crura. Instead of this we perform relaxing incisions of diaphragm to make it possible to suture the crura. After this we cover the defects with mesh.

We place the remnants of the hernial sac, omentum flaps or lipomas between the mesh implant and the esophagus as a "spacer".

Finally, we perform the fundoplication in such a way as to avoid contact between the edges of the mesh and the esophagus.

Results: For the period from 2000 to 2020 in our clinic 2490 patients with GERD and HH underwent antireflux surgery, 1200 patients had large HHs. In 692 cases of HH repair mesh implants were used. Mesh related complications were detected in 12 patients (1.73%). Redo operations were performed in 12 patients. In 7 patients, the mesh was removed completely. In 1 patient, the mesh was removed and the mediastinum was drained (leakage stopped after 4 weeks). In 3 patients the migration of nitinol mesh into the esophageal lumen occurred. It was possible to remove it endoscopically with the subsequent installation of special stents. Good results were obtained in 10 of 12 patients after reoperation. Dysphagia was observed in 2 patients after reoperation, it required repeated balloon dilation and stent placement in one case.

Conclusion: We believe that the proposed surgical maneuvers are effective in preventing of mesh erosion and migration and can reduce the number of redo operations.

UPPER GI—Reflux-Achalasia

P229—Our Standard Procedure by Right Side Approach in Laparoscopic Nissen Fundoplication for GERD Patients

Tatsushi Suwa, K. Iwasaki, A. Obana, S. Usui, N. Koide, K. Kitamura, T. Matsumura, M. Nakayama, K. Karikomi, M. koyama, Y. Sato, R. Yoshida, H. Suzuki, S. Masamura, H. Nomori

¹Kashiwa Kousei General Hospital, Surgery, Japan

Introduction: Laparoscopic techniques in anti-reflux surgery for GERD patients are still considered complicated. We have established our simple anti-reflux surgery procedure with right side approach contributing to less bleeding and less operative time.

Surgical Procedure Setting: Our 5-trocar setting with patients in the reverse Trendelenburg's position is as follows: 12 mm trocar just below the navel (A), 5 mm trocar at the upper right abdomen for pulling up the liver, 5 mm trocar at upper right, 12 mm trocar at upper left (B), 5 mm trocar at middle left (C).

Step 1: Right Side Approach.

Left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus of the diaphragma has been dissected free from the soft tissue around the stomach and abdominal esophagus. In this step the fascia of the right crus should be preserved and the soft tissue should not be damaged to avoid unnecessary bleeding. After cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. Then the inside and outside margins of the left crus of the diaphragma were recognized from the right side. The laparoscope uses trocar (A), the assistant uses trocar (B) to pull the stomach and the operator’s right hand uses trocar (C).

Step 2: Flap Preparation.

The branches of left gastroepiploic vessels and the short gastric vessels were divided. The left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was shown and widely opened. The laparoscope uses trocar (A) at the beginning of dividing left gastroepiploic vessels, trocar (B) when dividing short gastric vessels.

Step 3: Suturing.

The right and left crus are sutured with interrupted stitches to reduce the hiatus. From the right side, the fundus of the stomach is grasped through the window behind the abdominal esophagus. Then the fundus of the stomach is pulled to obtain a 360 degree "stomach-wrap" around the abdominal esophagus. Stitches are placed between both gastric flaps.

Results: We have performed this procedure in 128 cases. The mean operation time in recent 20 cases is about 70 min. The patients are mostly satisfied with the postoperative results because of stable food passage and no reflux.

UPPER GI—Reflux-Achalasia

P230—Gastro-Esophageal Reflux Test determining Surgical Indication for GERD Patients and Results of Laparoscopic Nissen Fundoplication

Tatsushi Suwa, K. Iwasaki, A. Obana, S. Usui, N. Koide, K. Kitamura, T. Matsumura, M. Nakayama, K. Karikomi, M. Koyama, Y. Sato, R. Yoshida, H. Suzuki, S. Masamura, H. Nomori

¹Kashiwa Kousei General Hospital, Surgery, Japan

Introduction: The indication of laparoscopic anti-reflux surgery for GERD patients is difficult to be determined fairly. We have established “Reflux Test “ as a useful tool to determine surgical treatment for GERD patients.

Surgical Indication Reflux Test: At the standing position a patient swallows 300 ml barium solution. After total solution goes into stomach, a patient lies down at the flat position. Then a patient changes the position to left lateral decubitus position, flat position, right lateral decubitus position and flat position again every 10 s in the order. During this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. If the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. The anti-reflux surgery was considered in the moderate and severe categories.

Results: We have performed laparoscopic Nissen procedure in 128 cases. Median follow-up period of this study was 81 months (2–145 months). In 18 cases (14.1%) PPI was restarted before 6 months after the anti-reflux surgery. In 32 cases (25.0%) PPI was restarted after the anti-reflux surgery during the whole follow-up period of this study. The results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the PPI restarted group which was analyzed by our endoscopic esophagitis grading score (p < 0.001).

Conclusion: The anti-reflux surgery is most effective for the patients who really have the obvious reflux. The results of the laparoscopic Nissen fundoplication were good and satisfied by the patients mostly.

COLORECTAL—Benign

P231—Endoscopic Management of Delayed Perforation of the Rectum Caused by Foreign Body Entering Anus

A. Bozkurt, Levent Eminoğlu, L. Eminoğlu Eminoğlu

¹Kadıköy Florance Nightingale Hospital, General Surgery, Turkey

Rectum perforation caused by a foreign body (FB) is a common presentatition. It occurs mostly patients with chronic constipation whose use an instrument for defecation.

Delayed perforation of the bowel by a FB can also occur, but is even more common. The ideal management of perforation of the colon by endoclip remains to be established because of its very low incidence. Definite surgery is the usual treatment. Here, we report on a 18-year-old male patient who presented with severe rectal and urethal bleeding owing to rectal and bladder perforation caused by a wooden stick. A computed tomography scan revealed that the fistula with rectum and bladder. This was further confirmed by colonoscopy after bowel preparation. Rectal perforation was closed using 5 endoscopic clips. The patient made an uneventful recovery.

COLORECTAL—Malignant

P232—Transforming Growth Factor—Beta-Induced Protein Using Human 3D Organoids: A Novel Immune Check-Point in Colorectal Cancer?

Andrea Picchetto ¹, M. Chiaretti², I. Celardo³, F. Frattaroli², V. Barnaba³, G. D'Ambrosio⁴

¹Sapienza University of Rome, Policlinico Umberto I University Hospital, Emergency-Acceptance, Critical Areas and Trauma Department, Italy, ²"Umberto I" University Hospital, "Sapienza" University of Rome, Department of General Surgery and Surgical Specialties, Sapienza University of Rome, Rome, Italy, Italy, ³"Umberto I" University Hospital, "Sapienza" University of Rome, Department of Internal Clinical Sciences, Anesthesiology and Cardiovascular Sciences, Italy, ⁴"Umberto I" University Hospital, "Sapienza" University of Rome, Department of General Surgery “Paride Stefanini”, Italy

Introduction: The transforming growth factor—beta-induced (TGF-I) protein was found significantly upregulated in colorectal cancer (CRC) secretome (secreted proteome) as compared with the non-tumor. TGFBI is an RGD-containing extracellular matrix protein that binds to type I, II and IV collagens, serves as a ligand recognition sequence for several integrins, and inhibits cell adhesion. Its release from primary tumors has been associated with increased tumor proliferation/migration/metastasis, but its role as secreted immune check-points (sICs) has not been fully investigated.

Methods: A LC/Mass-spectometry (Orbitrap)-based platform was set up to identify the secretome in conditioned medium (CM) from fresh tumor and non-tumor surgery samples (20 patients). By this approach, we selected a multitude of secreted proteins that were upregulated in CRC secretome as compared to the non-tumor, in order to identify those potentially acting as sIC.

Aims: Their discovery may represent a tremendous resource for tumor specific drug targets, potentially acting as sIC inhibitors in both cold and hot tumors, unlike current IC inhibitors (e.g., IpilumumAb and NivolumAb).

Results: We first validated by Elisa that TGFBI was overexpressed in CM tissue samples and in serum from CRC patients (as compared with non-tumor patients), and positively correlated with the tumor stage.

Interestingly, tissue-IHC and confocal microscopy revealed that TGFBI was overexpressed by tumor cells, T cells, monocytes and plasma cells in tumors in a significantly higher extent than in non-tumor, suggesting a massive involvement of the tumor microenvironment (TME) in secreting it. These data are also confirming at the level of the same cell populations isolated from tumor tissues. Importantly, the recombinant form of TGFBI, as well as the tumor CM containing high levels of native TGFBI, significantly inhibited various functions (IFN- and TNF- production, GZB and T-bet expression…) of anti-CD3/CD28-activated CD4 and CD8 T cells, which could be restored by the addition of the neutralizing anti-TGFBI mAb in vitro.

Finally, we are validating that TGFBI can act as a sIC by using human 3D CRC organoids as a surrogate of animal models in vivo. Human 3D-organoids generated from various tumor tissues allow to determine the interaction between tumor and immune system, the response (activation, cytokine production, killing…) by autologous CD8 and CD4 T cells derived from cancer patients, the role of sICs in inhibiting anti-tumor T cell response, the role of related sIC inhibitors in unlashing the anti-tumor T cell response.

Conclusions: TGFBI with human 3D CRC organoids can act as a tremendous effective sIC inhibitors in CRC patients. Furthermore, human-based models, such as human organoids, can offer effective ways “to accelerate transition to a research system that does not involve testing on animals”, as the European Parliament has recently declared (see go.nature.com/3hzprhj).

COLORECTAL—Malignant

P233—Are Distended Small Bowels and a Dilated Cecum on CT-Scan Associated with Worse Outcome Following Emergency Resection for Left-Sided Obstructive Colon Cancer?

Bas Kertzman ¹, F.A. Amelung¹, E.C.J. Consten², P.J. Tanis³, W.A. Draaisma¹

¹Jeroen Bosch Ziekenhuis, Surgery, The Netherlands, ²Meander Medisch Centrum, Surgery, The Netherlands, ³Amsterdam UMC, Surgery, The Netherlands

Background: Emergency resection for left-sided obstructive colon carcinoma (LSOCC) is associated with high morbidity and mortality, especially in patients with a high age or ASA-grade. No other risk factors have yet been identified. Identification of high-risk patients could aid in determining which patients could benefit most from a bridge-to-surgery approach. The aim of this study is therefore to determine whether certain characteristics on CT-scan (small bowel ileus/cecum diameter > 9 cm) are predictive of a worse outcome.

Methods: Patients were selected from a database that was created through a national collaborative research project. All Dutch patients that underwent resection for LSOCC from 2009 until 2016 of whom both CT characteristics were reported, were included. They were subsequently divided across four groups depending on the presence of a small bowel ileus and a cecal diameter of > or < 9 cm.

Results: 937 patients were included. Patients with both a small bowel ileus and a cecum > 9 cm had significantly more 90-day complications (44.6% vs. 35%, p = 0.036), a higher mortality (6.5 vs. 2.3%, p = 0.047) and more often had a permanent stoma (52 vs. 41.7%, p = 0.026) compared to patients with neither CT characteristics (Table 1). Subgroup analysis of ASA I-II patients also revealed a higher 90-day complication rate in patients with both CT characteristics (57.1 vs. 42.4%, p = 0.007). Interestingly, patients with distended small bowels on CT-scan had a very high anastomotic leakage rate compared to the other groups, although not statistically significant when compared to group one (19.3 vs. 9.0%, p = 0.062).

Conclusion: Patients presenting with LSOCC that have both a dilated cecum > 9 cm and a small bowel ileus seem to have a higher risk of complications and death following emergency surgery.

COLORECTAL—Malignant

P234—Elective- Versus Emergency Surgery for Right-Sided Colon carcinomas: A Propensity Matched Analysis of a National Database

Bas Kertzman ¹ , F.A. Amelung¹, T.A. Burghgraef¹, E.C.J. Consten², W.A. Draaisma¹

¹Jeroen Bosch Ziekenhuis, Surgery, The Netherlands, ²Meander Medisch Centrum, Surgery, The Netherlands

Aims. In past studies, anastomotic leakage rates following resection for right-sided colon carcinoma (RSCC) have been reported to be lower compared to left-sided resections. Because of this, resection with primary anastomosis for RSCC is deemed safe, in both elective- as well as the emergency setting. Recent studies however suggest higher complication rates, including anastomotic leakage, following emergency surgery. The aim of this study is therefore to determine the difference in complication rates between elective- and emergency resections.

Methods. All Dutch patients who underwent resection for a RSCC from 2010 until 2019 were identified from the Dutch Colorectal Audit (DCRA), a national database for colorectal cancer. Patients undergoing emergency resection were compared to patients undergoing resection in an elective setting following one-to-one propensity score matching.

Results: Of the 39,601 patients with a RSCC in the DCRA, 5625 underwent emergency surgery. 4631 were matched one-to-one to an electively operated patient. After matching, no differences in baseline characteristics were found. Anastomotic leakage rates did not differ between the treatment groups (5.7 vs. 5.8%, p < 0.904), while mortality was twice as high in the emergency surgery group (Table 1). Furthermore, emergency surgery patients had more 90-day complications (42.2 vs. 34.5%, p < 0.001) and significantly fewer radical resections (92.1 vs. 94.6%, p < 0.001).

Conclusion: Emergency resection for RSCC, when compared to elective surgery, is associated with a higher risk of complications and a mortality-rate that is twice as high. A bridge-to-elective surgery, which has seen a surge in popularity for left-sided obstructions, might therefore also be beneficial for these patients. Further research is needed.

HEPATO-BILIAIRY & PANCREAS—Liver

P235—Lessons Learned from the First Experience of Laparoscopic Right Posterior Sectionectomy

B. Lee, H.S. Han, Y.S. Yoon, J.Y. Cho, H.W. Lee, J.S. Lee

¹Seoul National University Bundang Hospital, Hepatobiliary Surgery, Korea

Laparoscopic right posterior sectionectomy (RPS) is one of the most technically challenging procedure. The purpose of the video article is to describe the difficulties and pitfalls from first experience of laparoscopic RPS and to share the tips for beginner; experienced senior surgeons share his advice for laparoscopic RPS.

Case presentation: The patient was a 79-year-old male was referred for hepatectomy because of a 4.2 cm sized hepatocellular carcinoma (HCC) at the right posterior section (RPS). Initially, a cholecystectomy and mobilization of right liver was performed in the usual manner. [Challenging 1) Inflow control] This part of the operation is technically demanding, especially in the hand of beginners. However, adequate access to right posterior glisson (RPG) is essential. If it is difficult to completely isolation of the RPG using sling, a bulldog clamp can be applied for inflow control. [Challenging 2) Parenchymal dissection] The laparoscopic RPS requires a longer parenchymal transection distance than right hepatectomy. Thus, we should reduce the bleeding from the resection line during identification and dissection of blood vessels and biliary tracks. If uncontrolled bleeding occurs at multiple points, the gauze compression methods can be used to reduce bleeding from the resection margin. [Challenging 3) Exposure of right hepatic vein (RHV)] The RHV should be exposed to obtain an adequate resection margin. If the RHV exposure is difficult, the use of intraoperative ultrasonography as an aid to liver resection.

Conclusion: The laparoscopic RPS is feasible safe when performed in experienced surgeons. However, it is a complex and difficult procedure for young surgeons, including controlling the inflow, reducing the risk of bleeding and ensuring an adequate the resection margin. Before overcoming the learning curve, the young surgeon must be balanced between patient safety and surgical steps.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P236—Walled–Off Pancreatic Necrosis as Complication of Acute Pancreatitis After SARS-COV-2 Infection: Endoscopic Mangement by Using Hot Axios System. A Case Report

S. Tontoli, Beatrice Pessia, G. Di Donato, D. Meloni, L. Romano, M. Schietroma, B. Pessia

¹San Salvatore, General Surgery, Italy

Aims. Approximately 15% of patients with severe acute pancreatitis will develop a serious complication called Walled-Off Pancreatic Necrosis (WOPN), defined as an encapsulated collection of pancreatic or peripancreatic necrosis with a well-defined inflammatory wall, usually occurs ≥ 4 weeks after onset of necrotising pancreatitis. WOPN is burdened by a very high mortality (20–30%) which can become higher (70–93%) with the presence of infected necrosis. On average, 40% of patients with necrotizing pancreatitis develop organ failure and 50% of the severe form of pancreatitis with infected necrosis or haemorrhage die post-operatively.

During the Covid Era, many cases of idiopathic, severe, acute pancreatitis in patients with SARS-CoV-2 infection or in the immediate post-negativization period were described.

We report a case in whom SARS-CoV-2 caused acute severe hemorrhagic necrotizing pancreatitis and the minimal invasive strategies implemented, which can considered maybe the only way to improve the outcomes for patients with WOPN.

Methods. A 68-year-old woman, whit a history of PCR confirmed SARS-CoV-2 infection three weeks earlier, not vaccinated, was admitted to our unit with acute abdominal pain with both laboratoristic and radiological studies suggestive of severe hemorrhagic necrotizing pancreatitis complicated by pancreatic infected pseudocysts and upper intestinal obstruction. To achieve hemodynamic stability aggressive fluid resuscitation was started. Then the patient was treated by nonsurgical approach: a percutaneous drainage was placed in the peri-splenic infected necrotic collection. She also began a targeted antibiotic therapy against E. fecium with gradual clinical improvement.

A CT scan performed two weeks after the procedure showed the reduction of collection, but persistence of a peri-pancreatic collection with compression of the gastric body. Therefore the patient underwent endoscopic ultrasonography (EUS)-guided transgastric WON drainage using the Hot AXIOS metallic stent.

Results: We obtained the complete drainage of necrotic collection and resolution of occlusive symptoms; the patient was discharged in free diet and with restored glycemic control. At eight months follow-up the woman was in good condition with complete recovery.

Conclusion: Although WOPN is burdened by a very high mortality, we believe that a multidisciplinary and mini-invasive approach can be considered the first-line treatment expecially to manage septic and obstructive complications, reducing perioperative mortality.

HEPATO-BILIAIRY & PANCREAS—Pancreas

P237—Utility of the use of intraoperative ultrasound in laparoscopic pancreatic surgery

Sergio Cerrato Delgado ¹, V. Martinez¹, M. Fonseca¹, C. Ramirez², P. Garcia²

¹Hospital Universitario Puerta del Mar, Cirugía General y Digestiva, Spain, ²Hospital Puerta del Mar, Cirugía General y Digestiva, Spain

Objective: To discuss the use of intraoperative pancreatic ultrasound in laparoscopic pancreatic surgery for diagnostic confirmation and surgical delineation.

Method: 55-year-old patient presenting with multiple non-functioning pancreatic neuroendocrine pancreatic tumors in the setting of MEN type I syndrome. History of total thyroidectomy for primary hyperparathyroidism and microprolactinoma in treatment with carbegoline.

CT: Two nodular lesions in pancreatic tail. Subcentimeter nodule enhancing in pancreatic body. MRI confirms 2 nodules in the pancreatic tail of 23 and 36 mm, as well as another one of 5 mm in the pancreatic body. Echoendoscopy showed up to 9 hypoechoic solid lesions of 25–25 mm in the head, body and tail of the pancreas, with two larger ones in the tail. FNA was performed and the anatomopathological results were suggestive of tumor with neuroendocrine differentiation.

Total vs. subtotal pancreatectomy was proposed based on intraoperative ultrasound findings. A French approach was performed with 5 trocars (3 of 12 mm and 2 of 5 mm), as shown in the image. Intraoperative ultrasound was performed and multiple pancreatic lesions were observed, mainly located in the pancreatic body and tail.

Result: The immediate postoperative period passed without complications and she was discharged on the 5th day. The final pathology report described 8 grade 1 neuroendocrine tumors (ki 67 less than 3%) that did not reach the resection margin. At subsequent revisions the patient remains uncomplicated.

Conclusions: Intraoperative ultrasound is a useful tool that can aid in intraoperative decision making in laparoscopic pancreatic surgery.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P238—O.S.A.T.S. System:Objective Structured Assessment of Technical Skill. Italian Society of Surgery School: Our Experience.

Maria Grazia Esposito ¹, G. De Sena², D. Russello³, N. Di Lorenzo⁴

¹Ospedale del Mare, Department of Endocrine and Ultrasound-Guided Surgery, Italy, ²Vanvitelli University Naples, Department of Surgical Science, Italy, ³Catania University, Department of Surgical Science, Italy, ⁴Roma Tor Vergata University, Department of Surgical Science, Italy

In the last five years in the framework of the activities of the Italian Society of Surgery School on: "Technological innovation: clinical aspects and research methodology", a structured surgical training was proposed.

Every year 15 post-graduate students and new surgical specialists underwent a full-intensive surgical training on minimally invasive techniques.

Structured from single tasks to most complex procedures, with a clear procedural step-by-step protocol of increasing difficulties, starting from a dry laparoscopic simulator, then moving to the Wet Lab, and finally to the Animal Lab and Robotic VR Lab. The OSATS system (Objective Structured Assessment of Technical Skill) was used to monitor them while performing the exercises.

Learners tutored by menthors on every single task of the three day -full immersion- course.

The results of the the students were compared. The learners who carried out procedural step-by-step protocol of increasing difficulties, showed a better result in time and effectiveness of implementing advanced skills.The results were statistically evaluated by mean of time spending during the exercises eye -hand coordination and bimanual coordination, showing that the consequentiality of the exercises, performed with increasing difficulty, reduces the execution time and improves the performance of the surgeon. The use of the OSATS system allows to measure the shortcomings of the Students in order to suggest the indications for the improvement of the technique.

The authors propose to suggest with their experience of about 5 years a validated system of teaching and objective judgment of surgical training. It could be an objective method of surgical evaluation of the post Covid era, compared with the results obtained in the pre-Covid years.

ROBOTICS & NEW TECHNIQUES—Liver

P239—Robotic and Open Resection for perihilar Cholangiocarcinoma: Comparative PSB-based Analysis of Short-term Outcomes and Survival (Single-Center Experience)

Natalia Elizarova, M. Efanov, A. Alikhanov, Y. Kulezneva, O. Melekhina, I. Kazakov, A. Vankovich, A. Koroleva

¹The Loginov Moscow Clinical Scientific Center, HPB Surgery Department, Russia

The aim of the study was to compare short term outcomes and survival after robotic and open liver and bile ducts resection for perihilar cholangiocarcinoma (PHCC).

Methods: Since October 2013, more than 140 patients with PHCC have undergone radical surgery at the Loginov Moscow Clinical Research Center. Since March 2014, the use of robotic access has begun (16 patients in total). Propensity score matching (PSM) was used for comparative analysis of single-center open and robotic resection outcomes. The balance of covariates was evaluated using standardized mean differences. Using COX regression analysis, we determined predictors for survival and compared groups of robotic and open resection according to them.

Results: There were no differences in short-term outcomes, including morbidity and 90-day mortality, between the groups of robotic and open resection. After PSM, 4-year overall survival was 50% and 63% (P- = 0,428), and recurrence-free survival was 45% and 52% (P = 0,511) in the robotic and open groups, respectively. No significant difference was found between values of short-term oncological outcomes in terms of number of lymph nodes harvested and the rate of R0 resection with tendency to more frequent R0 resection in robotic group before and after PSM. Immediate surgical outcomes, including morbidity, type of complications, mortality and length of hospital stay were comparable in two groups. There was no differences in the overall and recurrence-free survival between two groups.

Conclusion: Robotic approach is not inferior to standard open resection in terms of immediate outcomes. The minimally invasive technology in PHCC treatment are not yet established sufficiently to exclude the influence of learning curve on survival after surgery. In the current study, survival after robotic resection was not inferior in comparison to open resection; nevertheless, the selection biases could not be excluded despite the propensity score matching. The selection criteria for minimally invasive surgery for PHCC remain unclear.

SOLID ORGANS—Spleen

P240—Laparoscopic Splenectomy for Hereditary Spherocytosis

Alessia Fassari, A. Biancucci, M.M. Lirici

San Giovanni Addolorata Hospital Complex, General Surgery, Italy

Aim: Hereditary spherocytosis (HS) is the most common inherited hemolytic anaemia. The disease is caused by a defect in the erythrocyte cell membrane causing abnormal, spherical shape of red blood cells (so-called microspherocyte). The classical clinical features of haemolysis are anaemia, jaundice, and splenomegaly. Symptoms can develop in infancy, but some people with HS have no symptoms or minor symptoms and are diagnosed later in life. Surgical removal of the spleen is used as a cure for HS in case of severe anaemia and poor QoL as a consequence of recurrent haemolytic crises.

Materials and Methods: A 38-year-old man was admitted for severe anaemia with increased need for red cells transfusions, history of haemolytic crisis, mild jaundice and significant splenomegaly. Blood smear, reticulocytes count, bilirubin concentration, osmotic fragility test and direct Coombs test were studied. The diagnosis was confirmed by a positive flow cytometric analysis of eosin-5-maleimide (EMA)-labelled red blood cells (RBCs). Preoperative ultrasonography showed severe splenomegaly (22 × 15,5 × 9 cm) without cholelithiasis. The patient received immunisation for Haemophilus influenzae, Streptococcus pneumoniae and Meningococcus 2 weeks before surgery.

Splenectomy was performed through a 4-port laparoscopic approach and a Gagner oblique position on the right flank with thorax section of the table. The procedure of splenectomy began with the division of the splenocolic ligament followed by the section of the gastrosplenic ligament including the short gastric vessels. An accessory spleen was found and removed. The splenic hilum was dissected: first, splenic artery was skeletonized, clipped and divided, then splenic vein was carefully dissected from the pancreatic tail.

The splenorenal dissection and the division of lateral attachments to the spleen was furthered cephalad along the entire length of the spleen, with care not to enter the Gerota fascia. The splenophrenic ligament division allowed a complete spleen mobilisation. Although these planes are relatively avascular, the use of an energized device such as the ultrasonic activated shears can minimize tissue oozing. The specimen was removed with a retrieval bag through a minilaparotomy in the left flank connecting the left subcostal 12 mm-trocar incisions.

Finally the operating field was thoroughly rinsed and a drain left in situ.

Results: Postoperative course was uneventful. Bilirubin level decreased in the early postoperative period. Haemoglobin and RBC improved, and the effect was maintained during 4 months of follow-up. Doppler ultrasonography on postoperative day 7 was negative for portal splenic vein thrombosis.

Conclusions: Laparoscopic splenectomy is an effective technique when performed in patients with hereditary spherocytosis even in the case of large or massive splenomegaly. Proper technique and adequate surgical team training and experience are essential to perform the procedure safely.

SOLID ORGANS—Thyroid

P241—Treatment of Recurrent Lymph Node Metastases from Papillary Thyroid Carcinoma with Laser Ablation

Maria Grazia Esposito, C. Offi, C. Misso, U. Brancaccio, A. Nunziata, G. Antonelli, S. Spiezia

Ospedale del Mare, Naples, Department of Endocrine and Ultrasound-Guided Surgery, Italy.

The treatment of PTC is a total thyroidectomy with or without central lymphadenectomy followed or not followed by RAI therapy depending on the histotype and the presence of mutations. Lymph node recurrence can occur in about 1–2% of patients after surgical and RAI therapy. It can be treated with surgery or with additional RAI therapy, even if reoperations are burdened by a very high rate of major complications (25% of cases of vocal cord palsy) and metabolic radiotherapy is burdened by a very high failure rate when repeated. In fact, various studies have shown that neoplastic cells subjected to repeated RAI therapies lose the ability to pick up radioactive iodine. Ultrasound-guided mini-interventional procedures are an effective and safe alternative. The minimally invasive ultrasound-guided procedures have been developed and validated. They can be performed repeatedly without an increased complication rate, without hospitalization and general anesthesia; all characteristics well accepted by patients. Ultrasound guided. Laser Ablation (LA) Tecnique appears to be the safest and the most effective technique.currences. Therefore, LA can be considered an alternative treatment for patients who are unsuitable.We retrospectively enrolled 10 patients (5 males and 5 females) treated with a single LA session for a single lymph node recurrence. All patients had a diagnosis of classic variant PTC that had been previously treated with a total thyroidectomy and RAI.The ultrasound examination was conducted with a 7.5–12 MHz linear probe (MyLab™ ClassC and MyLab™ 9 Platform, Esaote Biomedica, Genova, Italy). The basal volume of the lymph node lesion was calculated using the software. Vascularity was studied by Color Doppler (CD) examination and slow flow analysis.We used a continuous wave multi-source laser system with a length of 1064 nm (EchoLaser ModiLite TM, Elesta SpA, Calenzano, Italy).The patients underwent a single LA session. The procedure was performed by placing the patients in a supine position with a moderate hyperextension of the neck. We performed a pericapsular local anesthesia with 2% Lidocaine. The applicators used were 21 Gauche (G) needles. We used an output power of 3 Watts in nine cases and a power of 4 Watts in only one case, due to the lymph node’s volume. The fibers used were quartz optical fibers with a flat tip and a diameter of 300 microns. The applicators were inserted into the target lesion through guides applied to the probe with different angles of incidence depending on the pre-treatment planning. All patients were treated with suppressive therapy with L-thyroxine. During the oncological follow-up, all patients had an increase in the serum Tg value greater than 20 μ g/L. The increase serum Tg was followed by an ultrasound of the neck which revealed the presence of disease. There were seven metastatic lymph nodes at level IV and three at level Vb with a baseline volume of 1.82 mL. In all cases, a FNAC of the suspected lesion was performed with a Tg assay on the eluate.Our series of 10 patients showed that a normalization of serum thyroglobulin levels, the absence of neoplastic cells in the control FNC and the absence of Tg in the eluate were recorded 6 months after the ablative treatment.

UPPER GI—Gastric cancer

P242—Tumor Budding Is a Risk Factor of Lymph Node Move in Early Gastric Cancer: A Retrospective Research

Xiang Ji ¹ , T. Yang¹, W.Y. Li¹, Y.D. Zhao², Y.T. Wang², Z.L. Yang¹

¹The Sixth Affiliated Hospital of Sun Yat sen University, Gastrointestinal Surgery, China, ²The Sixth Affiliated Hospital of Sun Yat sen University, Guangzhou city, China, Department of Pathology, China

Aims: To elucidate the correlation between tumor budding grade and clinicopathological characteristics in patients with early gastric cancer and determine whether it can be used as an independent predictor of lymph node metastasis in early gastric cancer, guiding whether the additional gastrectomy with lymphadenectomy is necessary after the endoscopic resection.

Methods: we evaluated 124 cases of EGC with pathological confirmation of T1a/T1b stage after the lymphadenectomy in our center from 2017 to 2020. Clinical data included gender, age, BMI, tumor site, Lauren, histologic type, T1a/T1b, LNM, en. Postoperative pathological specimens were evaluated using H&E staining and immunohistochemical staining (E-cadherin, CK7 maker). Two experienced pathologists assessed TB scores according to the Ueno “hot spot” method.

Results: Lymph node metastasis in EGC was significantly correlated with TB grade, tumor site, Lauren's staging, histologic type, T stage, and CK7 expression. In the ROC curve fitted by binary logistic regression analysis, TB had the most significant area under the curve, while TB was only correlated with T stage and BMI. LNM and TB were both not significantly associated with gender and age, while a significant statistical relationship was found between TB and LNM when adjusting for gender(male) or age(> 60).

Conclusions: High tumor budding is a risk factor for lymph node metastasis in early gastric cancer and may predict the possibility of continued tumor infiltration. Lymph node dissection based on radical resection of the primary site is necessary for patients with high TB, especially those with T1b stage, Lauren's grading of non-intestinal type, and intermediate—low differentiation.

UPPER GI—Reflux-Achalasia

P243—Hiatal hernia recurrences after laparoscopic surgery: exploring contributing surgical factors

Berdel Akmaz, E. Boerma, J. Stoot, B. Meesters, A. Hameleers

Zuyderland Medisch Centrum, Chirurgie, The Netherlands

Introduction: The current standard for laparoscopic repair of hiatus hernia (HH) involves crural repair and a Nissen (360°) or Toupet fundoplication (270°). However, literature shows that recurrences of hiatal hernia are still high after hernia surgery (> 42%). The most common type of recurrence is located anteriorly. Therefore, literature points out that additional anterior sutures could provide reinforcement. Furthermore, pledgets or mesh can be used to reinforce the crural repair. The effect of these reinforcement methods in the long-term (> 1 year) is still uncertain. Therefore, the aim of this study was to investigate the recurrence rate of hiatus hernia after laparoscopic fundoplication in a high-volume teaching hospital. Second, it was analyzed whether reinforcement techniques (mesh, pledgets and/or anterior sutures) lead to lower recurrence in the long-term.

Methods: In this retrospective database research all patients that had a laparoscopic fundoplication between 2012–2019 were included. The most important outcome variables were recurrence of symptoms and whether re-intervention had taken place. Statistical analyses comprised multi- and univariable analyses and chi-square tests.

Results: In total 307 patients were included, 206 (67%) women and 101 (32.9%) men. Patients received a Toupet (n = 208), Nissen (n = 78), Nissen-Rosetti (n = 20) or Dor fundoplication (n = 1) during primary surgery. The mean transverse diameter of the HH was 3.7 cm. In 132 patients (43%) anterior sutures were used, in 88 pledgets (28.7%) were used and mesh was used in 22 (7.2%) of the patients. 88 patients (28.7%) reported recurrent symptoms after primary surgery. 54 patients (17.6%) had secondary surgery and 4 (1.3%) patients had tertiary surgery. In the patientgroup with anterior sutures, only 31 (23.5%) reported recurrent symptoms. In the patientgroup with pledgets 21 patients (23.9%) reported recurrent symptoms. Additional significance analyses have yet to be conducted.

Conclusion: The recurrence rate amongst HH patients was 28.7%. 17.6% of the patients had secondary surgery. The Toupet fundoplication was used the most in our hospital and anterior sutures were used in almost half of the patients. Less recurrence was seen in patients with anterior sutures or pledgets. Additional analyses have yet to be conducted.

ROBOTICS & NEW TECHNIQUES—Technology

P250—Applications of 3D reconstruction, Augmented reality and 3D printing in Modern Surgical Education

Federico Espinola Schulze, M. Fayez Hassouna, M. Chand,

University College London, Division of Surgery and Interventional Sciences, United Kingdom

Introduction: Anatomy is the cornerstone of surgery. A confident grasp over applied surgical anatomy is essential for a surgeon to understand the target structures that need to be resected/repaired/removed and/or replaced, along with preserving the surrounding anatomy and preventing collateral damage. It is important that surgery should be taught as a combination of understanding applied anatomical variations, followed by manual techniques mastering. This allows for safe and appropriate surgical planning, as well as improves the surgeons ‘ breadth of experience and knowledge, and their ability to deal with the unexpected situations that may happen intraoperatively. We suggest that more attention should be paid to this aspect of training, that will offer a kind of extra gear in term of enthusiasm and ability to learn the basic methodology of navigating surgical practice.

Patient-specific three-dimensional modelling is a novel tool that helps us understand surgery and also helps teach. Surgical strategy can be discussed using MRI/CT scans, but it can be difficult to translate two-dimensional images into a surgical approach and also difficult to teach students. The use of Virtual and Augmented Reality together with 3D Printing allows to better visualize the anatomy in relation to the surrounding structures in addition to better approximating the size and shape of the abdominal organs. Our goal is to present an affordable solution that can be used in low-income countries also in educational centers.

Methods: Data are captured from MRI and CT scans, which are processed in various open-source software for smoothing, artefacts removal and decimation to achieve better performance. These images can be visualised in devices such as phones and tablets, taking advantage of native support in modern personal mobile devices, the goal is to superimpose computer-generated (CG) images on a real-world imagery and creating the illusion of AR in an affordable manner instead of video projectors, headsets, or computers.

Applications: Augmented reality: AR proved to be a great functional educational tool for medical students and junior surgeons. As regional anatomy has a much value than systematic anatomy in the practice of surgery, AR can use real-time patient-specific anatomical information to allow accurate reconstructions to better demonstrate the anatomy in relation to surrounding structures., It can also beneficially be used within pre, intra, and post operative applications. It helps in the pre-surgical planning, decision making, and the performance of live surgeries. AR gives the ability to navigate patient ‘s organs and structures. Allows to analyse the surgery, separate in steps, and practice different approaches. Enables to cut virtually and perform a virtual surgery before the surgery itself. Furthermore, AR can be used as a surgical objective assessment tool to evaluate how successful the surgery was. For example, AR can determine if the surgical objectives were completely accomplished or not, if all the tumour was safely resected, if any iatrogenic injuries happened, and so on. In case the surgical goals have not been, AR can possibly plan the next procedure more effectively.

Surgical Simulation: Once we have realistic models of the patient's anatomy, it is possible to create VR simulations of surgical procedures. This would allow to practice countless times and also to have several examples of anatomies for training. Besides, Thanks to 3D printing technology, we can create realistic models from the patient. Providing this tactile feedback to the models, adds a layer of realism which would improve the learning experience. Moreover, creating models for each patient before and after surgery to create a model collection for surgical training and minimally invasive procedures practicing.

Conclusion: It is possible to create realistic patient-specific AR models without proprietary software and to be visualised using low-cost mobile devices. Patient-specific anatomic modelling has several applications in surgery, from surgical planning to education. Augmented Reality in surgery promises to be a feasible way to improve the learning curves and surgical outcomes. However, further advances in artificial intelligence and image methods are still required to expand its capabilities, along with more research is necessary to validate its clinical use in surgical centres.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P251—Chitotriosidase and neopterin as biomarkers in acute cholecystitis

N. Vlad-Ionut¹, Emil Moiş ¹, C. Drugan², F. Graur¹, E. Moiş¹, N. Al Hajjar¹

¹Third Surgery Clinic, Prof. Dr. Octavian Fodor Regional Institute of Gastroenterology—Hepatology, Medical Informatics and Biostatistics, Medical Education, Faculty of Medicine, „Iuliu Haieganu” University of M, Romania, ²Medical Biochemistry, Department 3—Molecular Sciences, Faculty of Medicine, „Iuliu Haieganu” University of Medicine and Pharm, Medical Biochemistry, Department 3—Molecular Sciences, Faculty of Medicine, „Iuliu Haieganu” University of Medicine and Pharm, Romania

Aims: Gallstones are a common benign surgical pathology, twice as common for females. About 10–20% of the world's population will develop gallstones during lifetime and about 80% will be asymptomatic. Chitotriosidase and neopterin can be considered to evaluate the inflammation as products of macrophage activation. We aimed to evaluate the differences in chitotriosidase activity and neopterin levels between chronic and acute cholecystitis, and the influence of laparoscopic cholecystectomy invasiveness on postoperative biomarker variations.

Methods: A prospective cohort study was conducted from August 2019 to January 2021. Patients with laparoscopic surgery for gallstones at the Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, that gave their informed consent, were considered eligible. Blood samples were collected on EDTA (ethylenediaminetetraacetic acid) at presentation and at 24 h after surgery. Patients with biliary pancreatitis, cholestasis, cholangitis, reactive hepatitis, abnormal renal function or conversion to the classical procedure were excluded. Intraoperative appearance and the pathology report were used to determine the type of cholecystitis (atrophic or chronic cholecystitis vs catarrhal or gangrenous or phlegmonous cholecystitis with wall erosions and ulcerations).

Results: Fifty-one subjects with gallstones (thirty-six with chronic cholecystitis and fifteen with acute cholecystitis) were included in the study. A significantly higher level was observed at baseline for neopterin: 16.82 (13.53–21.36) nmol/L in acute cases vs. 11.91 (6.8–16.39) nmol/L for chronic cholecystitis (p = 0.019—Mann Whitney test). There were no significant differences for chitotriosidase activity: 160 (110–212.5) nmol/mL/h in chronic cholecystitis vs. 170 (90–295) nmol/mL/h for acute cholecystitis (p = 0.664—Mann Whitney test). When comparing the pre-postoperative values, no significant changes were observed after the laparoscopic intervention for neopterin [13.03 (7.77–18.34) nmol/L vs. 12.25 (8.84–20.62) nmol/L], neither for chitotriosidase [170 (110–230) nmol/mL/h vs 140 (110–195) nmol/mL/h]. Also no significant differences were observed in the postoperative values for neopterin neither for chitotriosidase regarding some additional invasive maneuvers: drainage, incision and aponeurosis enlargement, adhesiolysis or surgery time over 60 min.

Conclusions: Subjects with acute cholecystitis have a significantly higher neopterin level at presentation than those with chronic cholecystitis. Chitotriosidase and neopterin levels reveal no significant changes at 24 h after the laparoscopic approach.

ROBOTICS & NEW TECHNIQUES—Basic and Technical research

P252—Tools for quality assessment of technical skill in laparoscopic surgery; a systematic review

Annabel van Lieshout ¹ , A. Grüter¹, J. Ket², R. Hompes³, J. Bonjer¹, J. Tuynman¹

¹Amsterdam UMC, location VUmc, Surgery, The Netherlands, ²Amsterdam UMC, location VUmc, Medical Library, The Netherlands, ³Amsterdam UMC, location AMC, Surgery, The Netherlands

Aims. High technical performance of a laparoscopic surgeon seems to be associated with improved patient outcomes. There is a growing interest in objective assessment of surgical performance and many different video based assessment tools have been developed for laparoscopic surgery. However validation of these tools remain complex. We aim to provide an overview of the available video based tools for objective surgical quality assessment in laparoscopic surgery and their validation Results:

Methods. PubMed, EMBASE and MEDLINE were systematically searched by two reviewers to identify all studies focusing on video based quality assessment tools of technical skill in laparoscopic surgery performed by qualified surgeons in living patients. The validity evidence of these studies was assessed by using a validation scoring system.

Results: 47 studies with a total of more than 30 different video based quality assessment tools were identified used in 16 different laparoscopic surgical procedures. These tools can be separated in 4 categories: global rating scales, step-by-step procedure specific tools, error based rating scales and motion tracking software. 11 studies validated their tools with clinical patient outcomes, 20 studies used validation with experience of surgeons, 12 studies compared their tool with another tool and 11 studies used expert opinions. Both global rating scales and step-by-step procedure specific tools showed correlation of surgeon performance and improved short term patient outcomes.

Conclusion: This shows the variety of different tools used in laparoscopic surgery and their different validation methods. Measurement of surgical quality by using a tool seems to be a feasible method to objectively assess technical skill of a surgeon and may be associated with improved patient outcomes. However the evidence of validity in most of these studies was moderate. Future studies on video based quality assessment need to focus on different aspects of validity and patient outcomes to examine the impact of using a tool in daily surgical practice.

COLORECTAL—Benign

P253—Intra-abdominal actinomycosis—an indolent masquerader of malignancy

Balaji Jayasankar, ¹ K. Abdelsaid¹, Y. Abdul Aal¹, A. Papadopoulos¹

¹Maidstone and Tunbridge Wells NHS England, General Surgery, United Kingdom

Aims: We present a case of a 54 years old lady who presented with constitutional symptoms of lethargy, weight loss and asthenia. She had been extensively evaluated for a possible gynaecological malignancy but with no definitive outcome. The symptoms were persistent and a decision had to be made towards surgery in the present climate of the covid19 pandemic.

Methods: Following oncology multi disciplinary meeting outcome she was taken up for a total abdominal hysterectomy and bilateral salpingo-oophrectomy. She was noted to have an incidental finding of an extensive tumour infiltrating the liver, colon, anterior abdominal wall and the urinary bladder. A surgical resection with ileostomy was performed on suspicion of an underlying malignancy.

Results: The histopathological diagnosis revealed a picture of actinomycosis which had evaded us previously. Following this she was treated with prolonged course of antibiotics and has recovered well, thus altering our entire management plan.

Conclusion: Actinomycosis is an interesting masquerader of malignancy.

Result: This report proves invaluable lessons of a primary pathology while suspecting a. canver.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

P254—Is Laparoscopic Cholecystectomy a Bigger Challenge For a Leftie?! The Perspectives of Four Left Handed Surgical Residents

Estera Cristina Homorogan, S. Cuzmanov, D. A. Brebu, G. Noditi, G. Verdes, K. Botoca, C. Vilceanu, D. Al-jobory, V. Braicu, C. Tarta, F. O. Lazar, C. Duta

¹Spitalul Clinic Judetean de Urgenta Timisoara, 2nd General Surgery Clinic, Romania

The professional development of left handed surgical residents is a challenge for both the resident and his/her attending. We aim to emphasize the difficulties encountered by left handed surgical residents while performing a laparoscopic cholecystectomy (LC) and find solutions for improving their technique while mainly using their non-dominant hand. We selected four left handed and four right handed surgical residents with similar past experience and knowledge and analyzed their performance in the operating room (OR), each of them performing six LC for chronic, uncomplicated lithiasic cholecystitis. Data analysis showed that third and fourth year left handed resident encountered major difficulties during LC while mainly using non-dominant hand due to poor right hand abilities, undeveloped hand-eye-foot coordination and a lack of appropriate guidance from the attending surgeon. Fifth year left handed residents showed a reduction in the developmental gap between them and right handed colleagues, while no significant differences in performance were reported between sixth year left and right handed surgical residents, both having performed above 50 LCs prior to inclusion in this study. We concluded that left handed surgical residents develop even handed abilities in the course of their training because of their need to adapt to a right handed general setting and attending instructions, while right handed residents tend to disproportionally develop their right handed abilities compared to the non-dominant hand. Although initial challenges are bigger for a leftie, and require additional time, dedication and understanding of their particular situation, results show similar development at the end of their residency program, raising the question if a right handed approach is not all together better suited for a leftie.

BARIATRICS—Laparoscopic

P255—Preoperative assessment of severe complications before bariatric surgery by risk prediction models: Is it worth it?

Izabela Karpińska, J. Rymarowicz, P. Zarzycki, J. Kulawik, M. Maciej, M. Pędziwiatr, P. Major

¹Jagiellonian University Medical College, 2nd Department of General Surgery, Poland

Introduction: Bariatric surgery was proven to be effective and safe obesity treatment. Sleeve gastrectomy is one of the most commonly performed procedure worldwide. Obesity-related comorbidities contribute to the occurrence of complications after intervention. Preoperative assessment of possible outcomes seems to be crucial for surgeons in qualification process and perioperative care. Over past decade various tools predicting complications after bariatric surgery has been proposed.

Aim: We aimed to identify and validate available risk stratification models as the predictors of severe complications after sleeve gastrectomy.

Material and methods: The retrospective analysis included patients who underwent sleeve gastrectomy (SG) and completed 30-day of follow-up. The literature review was done to identify available risk stratification models. The score or odds of postoperative complications were calculated for each patient. Postoperative complications were defined as any abnormality reaching 3 or more stage in Clavien-Dindo Classification and occurring within 30 days after the operation. The relationship between predicted and actual outcomes were assessed by logistic regression analysis. Discrimination was evaluated by area under the receiver operating characteristic (AUROC) whereas calibration by Hosmer–Lemeshow test.

Results: Out of 997 patients enrolled 662 (66.40%) were women whereas 335 (33.60%) were men with mean age 41 years. The most common comorbidities were: dyslipidemia (69.71%), hypertension (63.29%) and obstructive sleep apnea (28.28%). Severe postoperative complications occurred in 1.71% of patients.

Literature review identified ten models. In logistic regression analysis only three of them had statistically significant capability of identifying severe complications (OR: 1.26–1.52). Two models including MBSAQIP Calculator and model proposed by Gupta reached reasonable discrimination with AUROC = 0.73 and 0.72 respectively. Moreover both of them did not lose their goodness-of-fit in Hosmer–Lemeshow test.

Conclusions: There are three tools which seem to be helpful in preoperative assessment of severe complications after sleeve gastrectomy. MBSAQIP Calculator and Gupta’s model seems to be more accurate than others. Further external validation of analysed models at the international level is needed.

Keywords: predictive models; external validation; severe complications; bariatric surgery; sleeve gastrectomy,

COLORECTAL—Malignant

P256—Required Distal Mesorectal Resection Margin in Partial Mesorectal Excision: a Systematic Review on Distal Mesorectal Spread

Alexander Grüter

¹Amsterdam UMC, Surgery, The Netherlands

Aim: Partial mesorectal excision (PME) is considered a valid alternative in proximal rectal cancer, but required distal margin is controversial. The systematic review aimed to determine incidence and distance of distal mesorectal spread (DMS).

Method: A systematic search using PubMed, Embase and Google Scholar databases was performed. For quality assessment, the Agency for Healthcare Research and Quality (AHRQ) methodological checklist was used.

Results: Out of 2493 articles, 20 studies with a total of 1742 patients were included, of whom 266 underwent neoadjuvant radiotherapy. DMS was reported in 181 (10.4%) specimens, with specified distance of DMS relative to the tumor in 84 (46%) of the cases. The maximum reported DMS was 50 mm in 1 of 84 cases. Mean and median DMS were 20.2 and 20.0 mm, respectively. Distal margins of 40 mm and 30 mm would result in 10% and 32% residual DMS, respectively, which translates into 1% and 3% overall risk given 10% risk of DMS. In subgroup analysis, for T3 the mean DMS was 18.8 mm (range: 8–40 mm) and 27.2 mm (range: 10–40 mm) for T4 rectal cancer. DMS was mainly determined by lymph node metastases (86.9%).

Conclusion: DMS occurred in 12.2% after surgery alone and 0.4% after radiotherapy, with a maximum of 50 mm in less than 2% of the cases. This indicates substantial overtreatment if routinely using a distal margin of 5 cm for PME, especially after radiotherapy. Prospective studies evaluating more limited margins based on high quality preoperative MRI and pathological assessment are required.

BARIATRICS—Laparoscopic

P257—Operating the inoperable patient: Morbid obesity and complex abdominal wall hernias

Catarina Mesquita Guimares, T. Moreira Marques, D. Melo Pinto, F. Marrana, L. Freire, P. Soares Moreira, R. Peixoto, T. Figueiredo Rama, G. Faria

¹Hospital Pedro Hispano, General Surgery, Portugal

Aims: To describe a group of patients submitted to bariatric surgery who presented with complex abdominal wall hernias at the time of bariatric surgery.

Methods: We performed a retrospective, descriptive, evaluation of a subgroup of patients with complex abdominal wall hernia from our prospective database that includes all patients submitted to bariatric and/or metabolic surgery from January/2018 to September/2021 by the Bariatric Surgery Group of a Portuguese community hospital. We assessed preoperative and post-operative, anthropometric parameters, hernia characteristics, surgical options regarding hernia management, operative parameters and complications.

Results: This study enrolled eleven patients, who presented with complex abdominal hernias at the time of the bariatric surgery. 82% of the patients were women. The mean body mass index (BMI) at the time of the surgery was 41,5. At the time of the hernia correction surgery the mean BMI was 29,4. The most performed surgery was gastric sleeve (45,4%), followed by gastric bypass (36,4%). 18,2% were one anastomosis gastric bypasses. All surgeries performed were laparoscopic, but two had to be converted due to intraoperative complications. In 72,7% of the patients a no-touch option was performed during surgery. In the other 27,3% reduction of the hernia was necessary to continue the surgery. At least 4 (36.4%) patients had intraoperative or postoperative complications. One patient required reintervention after surgery for an accidental perforation by the trocars. One patient required multiple percutaneous drainages for splenic abscesses.

Conclusions: Overweight and obesity have been shown to be the most significant predictor of recurrence of incisional hernia repair, with a rate of 1.1 per unit BMI increase above normal. Therefore losing weight before the hernia correction surgery improves hernia outcomes. Based on our study, bariatric surgery with a laparoscopic approach in patients presenting with complex abdominal hernias is feasible, but it’s associated with a significantly higher risk of complications.

COLORECTAL—Malignant

P258—Laparoscopic total pelvic exenteration for locally advance rectal cancer. A challenging case or a gold standard procedure?

Flaviu Ionut Faur ¹ , V. Schitcu², A. Clim³, I. Cojocaru², B. Borz², G. Lazar²

¹Oncological Institute Prof. Dr. Ion Chirircuta Cluj Napoca, I st Clinic of Surgical Oncology, Romania, ²Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania, Oncological Institute Prof Dr I Chiricuta CLuj Napoca, Romania, ³Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania, Romania

Total pelvic exenteration (TPE) may be the only procedure that can cure T4 rectal cancer that directly invades the urinary bladder or prostate. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection for advanced primary rectal cancer. A 44-year-old man diagnosed with advanced lower rectal cancer (T4bN1M0) underwent laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy. Ligation of the dorsal vein complex was performed under direct visualization Perineoplasty was performed using a dual mesh graft in association with pediculated omentum interposition. The total operative time was and 7 h and 30 min and estimated blood loss was 600 mL. Conclusion: MIS exenteration can be performed in highly selective cases, where there is favourable patient anatomy and tumour characteristics. When feasible, it is associated with reduced intra-operative blood loss, shorter length of hospital stay, and reduced morbidity. appears to be safe and feasible in selected patients.

UPPER GI—Gastroduodenal diseases

P259—Wilkie s Syndrome or Superior Mesenteric Artery Syndrom. The Minimally Invasive Approach a Challenging Experience or a Gold Standard Procedure?

Flaviu Ionut Faur ¹ , L. Stoica², C. Tarta³, M. Marian³, A. Isaic³, C. Duta³, A. Dobrescu⁴

¹Pius Brinzeu Clinical Hospital Timisoara, II nd Surgery Clinic, Timisoara Emergency County Hospital, Romania, Romania, ²II nd Surgery Clinic, Timisoara Emergency County Hospital, Romania, II nd Surgery Clinic, Timisoara Emergency County Hospital, Romania, Romania, ³Timisoara Emergency County Hospital, Romania, Romania, ⁴”Victor Babes” University of Medicine and Pharmacy Timisoara, Romania, Romania

Superior mesenteric artery (SMA) syndrome (known as Wilkie's syndrome or Cast syndrome) is a rare cause of upper gastrointestinal obstruction. It is an acquired disorder in which acute angulation of the SMA causes compression of the third part of the duodenum between the SMA and the aorta. This is commonly due to loss of fatty tissue as a result of a variety of debilitating conditions. Surgeries for spinal deformities as well as high insertion of the ligament of Treitz are other potential causes for the occurrence of SMA syndrome. Loss of retroperitoneal fatty tissue as a result of this variety of conditions is believed to be the etiologic factor causing the acute angulation. Symptoms vary from postprandial nausea and bilious vomiting to abdominal pain as well as weight loss and can occur acutely or chronically. The severity of the symptoms largely depends on the degree of the compression as reflected by the aortomesenteric angle.

In this paper 5 patients were included with of symptoms of duodenal obstruction. The approach in these patients was a laparoscopic one, the Gerssin-Heinford technique. The evolutionary dynamics of the cases was favorable with the restoration of the metabolic norms. The evolutionary dynamics of the cases was favorable with the restoration of the metabolic norms. We will present in detail the demographic characteristics of the study group as well as the analysis of some parameters with important impact in the evolution of the cases, respectively the statistically significant criteria.

HERNIA-ADHESIONS—Abdominal wall hernia

P260—Systematic Review and Meta-analysis Comparing Ventral Hernia Mesh Repair Using Minimally Invasive Totally Extraperitoneal Repair Versus Intraperitoneal Onlay Mesh Repair

Yegor Tryliskyy ¹ , A. Kebkalo², V. Tyselskyi², N. Ponomarov²

¹Royal United Hospital, Bath, Surgery, United Kingdom, ²Shupyk National Healthcare University of Ukraine, Surgery and Proctology, Ukraine

Background: This systematic review and meta-analysis analysed was set up to compare totally extraperitoneal mesh repair (TEP) and intraperitoneal onlay mesh placement (IPOM) in patients undergoing minimally invasive ventral hernia mesh surgery (MIS-VHMS).

Methods: A systematic literature searches of three major databases were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify studies that compared two techniques of MIS-VHMS: TEP and IPOM. Primary outcome of interest was major complications post-operatively, defined as a composite outcome of surgical-site occurrences requiring procedural intervention, readmission to hospital, recurrence, reoperation or death. Secondary outcomes were intraoperative complications, duration of surgery, surgical site occurrence (SSO), surgical site infection (SSI) postoperative ileus, length of stay, post-operative pain and requirements in postoperative analgesia. The risk of bias was assessed using Cohrane’s Risk of Bias tool 2 for randomized controlled trials (RCTs) and Newcastle–Ottawa score for observational studies (OSs).

Results: Five OSs and one RCT al including total number of 493 patients were included. There was no difference in primary outcome (RD 0.00; CI-0.07, 0.07; I2 62%), intraoperative complications (RD 0.00; CI -0.03, 0.02; I2 3%) (Figs. 1 and 2), SSO (RD 0.02; CI -0.09, 0.12; I2 74%) (Fig. 3), SSI (RD -0.01; CI-0.03, 0.01; I2 0%) (Fig. 4), incidence of postoperative ileus (RD -0.04; -0.1, 0.03; I2 68%) (Fig. 5). Operative time was longer in TEP (MD 40.05; CI 23.97, 56.14; I2 88%) (Fig. 6). TEP was found to be associated with less postoperative pain at 24 h and 7 days after surgery (Fig. 7,8). Majority of studies that analysed the need in additional analgesia confirmed superiority of TEP, although meta-analysis was not performed due to heterogeneity in reporting.

Conclusions: Both TEP and IPOM were detected to have equal safety profile and do not differ in SSO or SSI rates, incidence of postoperative ileus. TEP has longer operative time but provides better early postoperative pain outcomes. Further high-quality studies with long follow up evaluating recurrence and patient reported outcomes are needed. Comparison of other transabdominal and extraperitoneal MIS-VHMS techniques is another direction of future research.

PROSPERO registration: CRD4202121099.

UPPER GI—Gastric cancer

P261—LZAP as a novel biomarker signature predicting survival and adjuvant chemotherapeutic benefit in gastric cancer

You-Xin Gao, Chang-Ming Huang, K. Weng

¹Fujian Medical University Union Hospital, Gastric Surgery, China

Objective: To examine the clinical significance of LZAP to predict chemotherapeutic responsiveness in gastric cancer.

Background: We previously demonstrated that LZAP acts as a tumour suppressor in gastric cancer through negative regulation of the Wnt/β-catenin signalling pathway, but its function in chemotherapeutic responsiveness of gastric cancer has not been investigated.

Method: A collection of 188 pairs of tumour tissue microarray specimens from Fujian Medical University were employed for the discovery set, and 310 tumour tissue samples of gastric cancer patients were employed for the internal validation set. Eight-five tumour tissue samples from Qinghai University Hospital were used as the external validation set 1. Transcriptomic and clinical data of 299 gastric cancer patients from TCGA were used as the external validation set 2. LZAP expression, microsatellite instability (MSI) status, and tumour-infiltrating lymphocytes (TIL) were examined with immunohistochemistry. Clinical outcomes of patients were compared with Kaplan–Meier curves and the Cox model.

Results: In a multi-centre evaluation, increased LZAP indication of better prognosis depends mainly on MSI-L/MSS status or TILhigh. High LZAP expression predicts sensitive therapeutic responsiveness to postoperative adjuvant chemotherapy in gastric cancer. In a stratification analysis based on LZAP combined with TIL or MSI status, patients with LZAPlow TILlow showed no significant difference in prognosis after receiving chemotherapy, whereas patients with LZAPlow TILhigh, LZAPhigh TILlow, and LZAPhigh TILhigh had better responsiveness to chemotherapy. In addition, patients with LZAPhigh MSI-L/MSS status benefitted the most from adjuvant chemotherapy among all patients evaluated.

Conclusions: LZAP can be used as an effective marker to evaluate individualized chemotherapy regimens in gastric cancer patients dependent on their TIL and MSI status.

COLORECTAL—Benign

P264—Re-emerging Covid-19: Covid-19 specific consent in emergency and trauma surgery is here to stay longer

Dileep Kumar, M. Elsllabi, L. Martin, J. Khan, C. Vijayasekar

¹Ninewells Hospital/ NHS Tayside, General Surgery, United Kingdom

Background: Covid-19 has been proven to be additional peri-operative risk factor associated with significant increased risk of morbidity and mortality. GMC in light of Montgomery case, recommends discussing all material risks with patients during consent process. NHS Tayside introduced Covid-19 specific consent forms during the first wave, which was well utilized in elective surgery but was variably used across all surgical specialties during emergency and trauma surgery. This poses significant risk of clinical negligence and possible litigation.

Aim: This study reviews compliance of Covid-19 specific consent in emergency and trauma surgery, identifies factors for poor compliances and set processes to improve compliance.

Methods: This is prospective audit of Covid-19 specific consent for all emergency and trauma cases performed on CEPOD list for 1 week in Ninewells hospital, NHS Tayside. Outcomes of poor compliance analyzed and 3 step intervention made, including sharing outcomes with relevant surgical departments, ensuring availability of Covid-19 specific consent forms by stapling it with generic consent forms and making changes in CEPOD theatre booking form to ensure all adult patients (18 & above) have Covid-19 specific consent at the time of theatre booking. We re-audited our practice and seen massive increase in compliance.

Results: During first audit cycle we 92 patients were operated on CEPOD list and 81(88%) were enrolled for the study. 27 out of 81(33.3%) had Covid-19 related risk mentioned on routine form and only 1 patient had Covid-19 specific consent. We discussed the findings in Clinical effectiveness meeting and identified lack of insight, poor availability of consent forms and lack of supervision being main reasons of poor compliance. We shared the outcomes with all surgical departments to increase awareness, ensured availability of Covid-19 specific consent forms and made Covid-19 consent mandatory for CEPOD theatre booking. During second prospective audit cycle, 81 patients operated,72(88.8%) had Covid-19 consent, 2 patients had AWI and 1 child.

Conclusion: Covid-19 specific consent is mandatory in current ongoing pandemic and simple 3-step process of informing, helping and policing can improve compliance.

COLORECTAL—Malignant

P265—Outcome after Right Hemicolectomy with Special Focus on Anastomotic Leakage—A Retrospective Analysis on 641 Patients

Stefanie Schuster, C. Aigner, S. Raab, L. Rossetti, K. Szabo, A. Poljo, L. Huber, A. Shamiyeh

¹Kepler University Clinic—Med Campus III, Department of General and Visceral Surgery, Austria

Introduction: The right-sided hemicolectomy is a regularly performed abdominal surgery worldwide. Reasons for possible complications and the technique of the anastomosis, especially the occurrence of Anastomotic Leakage (AL), are still discussed controversially in the literature and considered a life threatening complication. Therefore, we analyzed our data retrospectively with special focus on anastomosis related complications.

Material and Methods: All patients who underwent a right hemicolectomy between 2010 and 2019 at the Department of General and Visceral Surgery at the Kepler University Clinic (KUK)—Med Campus III in Linz, Austria have been analyzed retrospectively. The following parameters were documented: Sex, age, BMI, indication for surgery, surgical approach, postoperative morbidity and mortality, technique of anastomosis, occurrence of AL, need for ileostomy, intraoperative peritonitis, postoperative revisional surgery, postoperative food intake, intraoperative peritonitis, corticosteroid intake at time of surgery, pain catheter, highest postoperative CRP level, lymph node stage (N) and the number of retrieved lymph nodes (in general and positive ones).

Results: Of 641 patients, 263 (41.0%) had laparoscopic resection (7.2% conversion rate) and 378 (59.0%) underwent open surgery. 239 (37.3%) of all patients got a hand-sewn anastomosis, whereas 375 (58.5%) received stapled ones which were mostly created extra-corporally. 26 (4.06%) patients got a terminal ileostomy and were therefore excluded from other calculations, resulting in a final patient collective of n = 615. The overall leakage rate was 3.9% (n = 24) with a postoperative mortality of 16.7% (4 of 24 patients with leakage, p = 0.015*). The occurrence of an AL was followed by average 1.92 (from 1 up to 8) revisional surgeries (p < 0.001**) between the 8th and 9th postoperative day. Eight (33.3%) of the leaking anastomosis were hand-sewn and 16 (66.7%) were stapled in acute (45.8%) or elective surgeries (54.2%).

Conclusion: The event of AL after right-sided hemicolectomy was rarely occurring and.

independent of the surgical approach as well as the anastomosis technique. Statistically significant differences in patients with leaks were found in the number of revisional surgeries, the ASA score, the postoperative 30-day morbidity and mortality, the length of the postoperative stay in hospital, highest postoperative CRP level and number of retrieved positive lymph nodes.

SOLID ORGANS—Adrenal

P266—Persistent disease and recurrence in pheochromocytomas. Experience from a series of 136 pheochromocytomas

Konstantinos Pateas, C. Aggeli, K. Pateas, C. Parianos, K. Leventakos, D. Stratigakos, V. Theocharidis, D. Kapnias, G.N. Zografos

¹General Hospital of Athens 'G.Gennimatas', 3rd Surgical Department, Greece

Background: Patients with pheochromocytoma or paraganglioma may present with residual disease or recurrence after the initial excision of the tumor. Although the grade of the tumor and the genetic predisposition play the most important role in the persistence of the disease, it seems that other factors, relevant with the first operation, contribute to their recurrence.

Aim: Our aim is to underline the importance of the recurrence at the progress of the disease through the presentation of 7 cases.

Methods: From a series of 911 adrenalectomies, 136 were in the final pathology report pheochromocytomas. We present 7 patients who were re-operated for pheochromocytoma. Five of them have been operated on in other hospitals. They were 4 men and 3 women, 27 to 78 years old. In the 4 patients, the first procedure was done laparoscopically, at the one with retroperitoneal approach and at the others transabdominally. Five patients had a short free-disease period with normal biochemical and imaging results, but they presented recurrence after a period of 2 years. The other 2 patients had residual disease after the first operation with persistence of biochemical and imaging findings and with concomitant difficult control of their hypertension. All the reoperations were done via laparotomy.

Results: Preoperatively, the patients were prepared with phenoxybenzamine and no one of them presented hemodynamic instability during the operation. Three right and 4 left open adrenalectomies were performed. The tumors had solid adhesions with the adjacent tissues but all were excised radically without macroscopic residual disease left behind and in one patient a concomitant splenectomy and left nephrectomy was done due to an invasion from the tumor(image 1).. One patient with residual disease at the site of the adrenal gland, also had adrenal tissue at the mesocolon of the transverse colon (pheochromocytomatosis) (image 2). A change at the PASS score was noted at all re-operations, from 1 to 4 from the first surgery to 6 to 8 in the reoperation. All patients had a normal postoperative course, with a mean time of hospitalization about 5 days.

Conclusion: The radical resection at the initial procedure is determinant for the progression of disease in patients with pheochromocytoma. Diligent post-operative follow-up is crucial for the primordial detection of the recurrence and its treatment.

ROBOTICS & NEW TECHNIQUES—Education

P267—Endoscopy Training of Physicians Residents in Experimental Training Center

A. Lozano Nájera¹, Paula Martínez Pérez ¹ , A. Terán Lantarón², J.I. Martin Parra³, P. Martínez Pérez¹, J.C. Manuel Palazuelos³

¹Hospital Universitario Marqués de Valdecilla, General Surgery, Spain, ²Hospital Universitario Marqués de Valdecilla, Endoscopy Unit, Spain, ³Hospital Universitario Marqués de Valdecilla, Colorectal Surgery, Spain

Aims: Develop a training program in digestive endoscopic skills in inanimate and animal models.

Methods: The program consists of 36 h divided into nine sessions. The first session consists of a theoretical approach on the knowledge of endoscopy and its instruments. Subsequently, the technique is performed on pig stomach and cow colon "ex vivo ". It begins with the practical use of the gastroscope and colonoscope to later progress in the difficulty of the techniques. Biopsies, polypectomies, removal of foreign bodies are perfomed, as well as adhesives acrylics, enteral prostheses are used ending with a submucosal endoscopic dissection.

The program is completed by performing the different techniques mentioned above on a live animal model. The entire program is instructed and tutored by the Endoscopy Unit of the Hospital.

This training program is combined with a one-month rotation in the Endoscopy Service Digestive.

Results: The training has been developed from 2006 to 2019. 33 doctors have participated. Satisfaction surveys were conducted at the end of the training. These showed that the program had brought new knowledge to the majority of the participants, without obtaining negative responses. In addition, 100% of the participants considered the carrying out training for their professional activity and would recommend carrying out the program the rest of the doctors.

Conclusions: Simulated training programs allow resident physicians to accelerate endoscopy training and facilitate its clinical implementation in the patient.

AMAZING TECHNOLOGIES

P270—Prognostic factors for the long term outcome after surgical celiac artery decompression in patients with median arcuate ligament syndrome (MALS)

Anna Woestemeier, A. Semaan, J. Dohmen, J.C. Kalff, P. Lingohr

¹University Hospital of Bonn, Germany, Department for General, Visceral, Thoracic and Vascular Surgery, Germany

Background: Surgical treatment of median arcuate ligament syndrome (MALS) aims to restore normal celiac blood flow by laparoscopic celiac artery decompression. However surgical success rates vary widely between patients, therefore adequate selection of patients is key to improve surgical outcome. So far, no specific parameters or imaging results were found to be predictive of this response.

The objective of this study was to identify preclinical parameters that help to distinguish patients that would benefit from surgical release can predict clinical response to laparoscopic release of the MAL in patients with celiac artery compression.

Methods: 20 patients diagnosed with MALS were included in this study and underwent laparoscopic MAL release between 2016 and 2021. The patients' preoperative and postoperative symptoms, patients' demographics, duplex abdominal ultrasonography (DUS) and CT angiography (CTA) findings were reviewed. Mann–Whitney-U-Test was used to identify correlation between patient or imaging variables and clinical outcomes.

Results: 60% of patients had a relief of their symptoms and simultaneous decrease of analgetic use after laparoscopic MAL release, while 8 patients (40%) had persistent symptoms. Neither sex, BMI, age, operation time nor the operation technique correlated significantly with symptom relief. However, mast cell activation syndrome correlated significantly (p = 0.04) with persistent symptoms after operation.

Conclusions: Overall, laparoscopic MAL release is an effective treatment for MALS and can provide immediate symptomatic relief. However, no specific imaging finding of stenosis was able to predict response to treatment. Our data show a correlation between persistent symptoms and a co-existing mast cell activation syndrome, suggesting that MACS symptoms might be interpreted as MALS symptoms in the presence of celiac artery stenosis and surgical treatment should be evaluated carefully. Overall, selection of patients who are most likely to respond to surgical MAL release may best be accomplished through a constellation of clinical and imaging findings with an interdisciplinary team of gastroenterologists, radiologists and surgeons.

AMAZING TECHNOLOGIES

P272—Complications and Outcomes in Laparoscopic Cholecystectomy

Rossen Madjov, P. Chernopolsky, V. Bozhkov, D. Chaushev

¹University Hopsital "St. Marina", Surgery, Bulgaria

Laparoscopic Cholecystectomy/LC/ is the gold standard for management of benign gallbladder disease. There are multiple anatomy/patient-related and surgical team-related risk factors that can contribute to the complexity of the procedure and increase the risk of intra- and postoperative complications.

The most important complications are: bleeding from the liver bed—5–8%; bile duct injuries—0,2–0,6%; minor vascular injuries—0,1–0,2%; major vascular injuries—0,07–0,2%; bowel lesions—0,07–0,4%; abdominal wall hematoma: case reports.

Authors analise 91 pts with iatrogenic bile duct lesions—diagnosis, treatment strategy and results /early and late/.

Prevention, early recognition and proper management are the triumvirate in surgical complications. The main questions are: Who? When? and How? to proceed in such patients.

If you diagnose a problem, choosing the correct route of action is not always easy and depends much on availability and approaches of imaging and interventional modalities /nonoperative management is possible in many situations—CT, ERCP and MRCP—both diagnostic and therapeutic modalities/ and surgical team practice in HPB surgery.

Early re-exploration may give an early diagnosis and allow early correction but it should be used selectively. Best results with lower morbidity and shorter hospitalization are associated with treatment performed in centers that specialize in hepatobiliary surgery.

AMAZING TECHNOLOGIES

P273—Cost-utility analysis of antibiotic therapy versus laparoscopic appendicectomy for acute uncomplicated appendicitis

Zina Mobarak ¹ , A. Ali², M. Al-Jumaily², M. Anwar², Z. Moti², N. Zaman², A. Reza Akbari³, L. de Preux²

¹King's College London, Faculty of Life Sciences and Medicine, United Kingdom, ²Imperial College London, United Kingdom, ³University of Manchester, United Kingdom

Aims: Current UK National Health Service (NHS) guidelines recommend laparoscopic appendicectomy as gold standard treatment for acute uncomplicated appendicitis. However, an alternative non-surgical management involves administrating antibiotic-only therapy with significant lower costs. Therefore, a UK-based cost-utility analysis (CUA) was performed to compare appendicectomy with an antibiotic-only treatment from an NHS perspective.

Methods: This economic evaluation modelled health-outcome data using the ACTUAA (2021) prospective multicentre trial. The non-randomised control trial followed 318 patients given either antibiotic therapy or appendicectomy, with quality of life (QOL) assessed using SF-12 questionnaires administered 1-year post-treatment. A CUA was conducted over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling using a propensity score-matched approach to control for selection on observable factors.

Results: The CUA produced an incremental cost-effectiveness ratio (ICER) of -£23,278.51 (-€27,227.80) per QALY. Therefore, for each QALY gained using antibiotic-only treatment instead of appendicectomy, an extra £23,278.51 was saved. Additionally, two sensitivity analyses were conducted to account for post-operative or post-treatment complications. The antibiotic-only option remained dominant in both scenarios. Conclusion: While the results do not rely on a randomized sample, the analysis based on a 1-year follow-up suggested that antibiotics were largely more cost-effective than appendicectomy and led to improved QOL outcomes for patients. The ICER value of -£23,278.51 demonstrates that the NHS must give further consideration to the current gold standard treatment in acute uncomplicated appendicitis.

COLORECTAL—Benign

P274—Treatment of colovesical fistula complicating diverticular disease in laparoscopic era: the truth is rarely pure and never simple

Antonia Rizzuto ¹ , U. Bracale², S. Reggio², C.D. Cuccurullo², F. Corcion³

¹University Magna Graecia of Catazaro, Medical an Surgical sciences, Italy, ¹University Federico II Naples, Department of General on Oncological Mini-Invasive Surgical Unit. Department of Advanced Biomedical Sciences. University, Italy, ²Department of General, Mini-Invasive and Robotic Surgery, Monaldi Hospital, Naples, Italy, ³University Federico II Naples, General and Oncological Mininvasive Surgical Unit. Department of Public Health. University Federico II of Naples, Italy.

Background: Colovesical fistulas (CVF) due to complicated diverticular diseases of the sigmoid colon are rare (4–20%) but account for about 60–70% of all CVF. Despite the existence in the literature of some studies on the laparoscopic management of colovesical fistulas (CVF), there is little evidence of real effectiveness and utility of minimally invasive approach to diverticular CVF compared to open surgery. Aim of the study is to evaluate the adequacy and utility of laparoscopy in the treatment of CVF complicating diverticular disease compared to open surgery.

Methods: Patients were recruited retrospectively among those who underwent surgery for CVC by diverticular diseases between 2010 and 2020. Demographic data, clinical parameters, preoperative diagnoses, operative data, postoperative data and histopathological examination were recorded prospectively.

The patients were assigned to 2 groups: the open surgery group (group A) and the laparoscopy group (group B).

Statistical analysis was carried out using the IBM SPSS Statistic 19.0 software package.

Results: Between January 2010 and December 2020, 76 patients (29 males, 47 females) underwent surgery for colovesical fistula by complicated diverticulitis.

Among the patients accrued for the study, 40 underwent laparoscopic surgery and 36 to open surgery. No statistical significance between the two groups were observed in terms of operative time (P = 0.56), bladder suture (P = 0.16) and associated surgical procedures (P = 0.009). Intraoperative blood loss (P = 0.04) Postoperative primary ileus (P = 0.003) and median length (P < 0.0001) of stay were significantly lower in the laparoscopic group.

The overall incidence of postoperative morbidity was 16.3% with differences between the two groups (P < 0.0001). Mortality occurred in one patient of the Group A (overall mortality 2.6%) and was not related to surgical complications.

No reoperations for postoperative complications were observed.

The median time of Foley catheter removal was not statistically different between the two cohorts (P = 0.33). Two years follow up shows no fistula recurrence.

Conclusion: Laparoscopic resection and primary anastomosis should be considered a safe and feasible option for the management of CVF by diverticular disease with rates of conversion, morbidity and mortality comparable to open approach.

Patients selection and surgeon experience are the cornerstones to obtain the best results.

AMAZING TECHNOLOGIES

P276—A Single Centre 20 Year Retrospective Cohort Study: Percutaneous Endoscopic Colostomy

Nicholas Farkas

Background: Percutaneous endoscopic colostomy (PEC) represents an important intervention in specific patients. Limited data currently exists. We present the largest recorded study of patients undergoing PEC.

Methods: Retrospective analysis of consultant logbooks highlighted all patients from 1997–2020. Two independent reviewers assessed records. Parameters measured; age, sex, indication, number of sites, complications, mortality and survival. Two subgroups were identified; recurrent sigmoid volvulus (RSV) and non-RSV.

Chi-squared test compared categorical variables and Kaplan–Meier curves to estimate survival. Log-rank test analysed differences between groups. A p-value of < 0.05 was considered statistically significant.

Results: 96 PEC insertions on 91 patients were included (5 reinsertions), 31 female (32%); mean age was 73 years (SD ± 15.2)). 72 procedures were for RSV, 24 for non-RSV. 27 (28%) patients experienced complications within 30 days, 23 RSV, 4 non-RSV, p value = 0.10. Nine patients leaked (9.9%), 8 RSV, 1 non-RSV, p value = 0.27. Five patients died following leaks. Overall 90-day mortality is 14.6% (14 patients), 4.2% (1/24) for non-RSV, 19.4% (13/67) for RSV, p = 0.08.

Median follow-up is 25 months (IQR 4.6–62.2 months). At 3, 5 and 10 years non-RSV survival was 58%, 42% and 36%, RSV survival was 35%, 18% and 8% respectively, p =  < 0.001.

Conclusion: Non-RSV patients appear to tolerate PEC with fewer complications and longer life expectancy compared to the poorer outcomes of RSV patients. We advocate high volume specialist units undertaking PEC. When determining patient suitability for PEC the high associated risks require careful consideration. Utilising risk stratification scores may help guide shared decision-making between patients, relatives and clinicians.

AMAZING TECHNOLOGIES

P277—Complete subadventicial laparoscopic pericystectomy of a cystic segment III-IVb liver lesion.

Alberto Fierro Aguilar, A. Valverde Martínez, A.A. Maestu Fonseca, M.D. Casado Maestre, M.J. Castro Santiago, J.M. Pacheco García

¹Hospital Universitario Puerta del Mar, General Surgery, Spain.

Aim: To report and discuss the case of a 69-year-old female patient diagnosed with hydatic cyst by image preoperatively in III-IVb liver segments. Laparoscopic surgery was performed successfully.

Method: A 69-year-old female patient attended for consultation due to abdominal pain, weight loss and asthenia. An abdominal CT (Computed Tomography) scan was performed, revealing a cystic lesion compatible with a 6 cm CE2 hydatid cyst (multifolliculated, fertile; Gharbi Classification) in segments III-IVb, that displaced the left posterior portal branch. Echinococcus granulosus antibodies were negative and MRI (Magnetic Resonance Imaging) ruled out any communication with the biliary duct. The patient was offered laparoscopic surgery which she accepted. During surgery, a lesion that looked like a hidatic cyst was observed lying above the left portal pedicle and a laparoscopic subadventitial pericystectomy was performed, as seen on the video. We used three 12 mm trocars (two working ports and one optical port) and two 5 mm accessory trocars. A difficult resection due to intense fibrosis was performed with CUSA (Cavitron Ultrasonic Surgical Aspiration) and hi-energy-device energy. A cholecystectomy and an intraoperative cholangiography were also performed, showing no signs of bile leak.

Results: The patient was discharged on the 7th day without any complications (Clavien-Dindo 1). The pathologist analysis showed a cystic lesion that showed lumens of different calibers delimited with cylindrical/cubic epithelium without atypia, PAS positive, and positive immunohistochemical expression for CK19 and CAM5.2. The underlying stroma was positive for estrogen and progesterone receptors expression. No signs of histological malignancy or hydatid cyst were observed, and it was diagnosed as biliary cystadenoma (hepatic mucinous cystic neoplasm).

Conclusion: Biliary cystoadenoma is an infrequent cystic neoplasm which can become malignant, usually diagnosed in female around 50-years-old with abdominal pain, weight loss or jaundice. Laboratory tests are normally of no use and image techniques such as CT or ultrasonography can help in the differential diagnosis. Colangio-RM can help showing possible communication between the cyst and the bile duct. If there is doubt of a possible cystoadenoma, surgery is mandatory. Deffinitive diagnosis will only be done by the pathologist.

AMAZING TECHNOLOGIES

P278—Revision strategies for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis

Rutger Franken

¹Spaarne Gasthuis, Surgery, The Netherlands

Objective. The aim of this meta-analysis was to assess revision intervention strategies for weight regain or insufficient weight loss following RYGB.

Background. Weight failure after RYGB is a major therapeutic challenge. However, a consensus on the most effective treatment is lacking.

Methods. A literature search (in PubMed and Embase) of revision interventions after RYGB was performed through September 2021. Measured outcomes included BMI at intervention, BMI/ TWL during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% CIs.

Results: 33 studies (n = 2533) were included. Fifteen studies reported on endoscopic interventions: three on APC, four on TORe, and eight on TORe + APC. After one year follow-up, pooled TWL was 7.61 kg (95% CI, 6.40—8.82), 5.27 kg (95% CI, 1.52—9.03), and 7.61 kg (95% CI, 6.08—9.14), respectively. Eighteen studies reported on surgical interventions (Fig. 1): four on pouch/GJA revision, five on LGB, two on pouch LGB + pouch resizing, seven on D-RYGB and one on DS. After one year follow-up, pooled BMI reduction was 6.44 kg/m2 (95% CI, 3.94—8.94), 5.17 kg/m2 (95% CI, 1.44—8.9), 8.5 kg/m2 (95% CI, 5.29—11.71), 8.44 kg/m2 (95% CI, 5.46—11.42), and 9.3 kg/m2 (95% CI, 6.05—12.55), respectively. Complications for surgical interventions were high compared to those for endoscopic interventions.

Conclusion: All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures resulted in modest transient weight loss. Other surgical revision techniques were successful in longer term follow-up, at the expense of high complication rates.

AMAZING TECHNOLOGIES

P279—Treatment options for weight regain or insufficient weight loss after sleeve gastrectomy: a systematic review and meta-analysis

Rutger Franken ¹ , N. Sluiter¹, J. Franken¹, D. Souverein², R. de Vries³, V. Gerdes⁴, M. de Brauw¹

¹Spaarne Gasthuis, Surgery, The Netherlands, ²Spaarne Gasthuis, Epidemiology, The Netherlands, ³Amsterdam UMC, Library, The Netherlands, ⁴Spaarne Gasthuis, Internal Medicine, The Netherlands

Obesity has reached pandemic proportions over the last decades. Bariatric surgery is the most effective treatment for obesity. Weight failure after sleeve gastrectomy (SG) is frequently observed (10–35%). Consensus on the most effective treatment is lacking. The aim of this meta-analysis was to assess revisional strategies for weight regain (WR) or insufficient weight loss (IWL) following SG.

A literature search (in PubMed and Embase) of revision interventions after SG was performed from inception up to May 04, 2021.

Twenty-two studies (1342 patients) were included. Two studies reported on endoscopic gastroplasty (ESG), five on re-sleeve gastrectomy (re-SG), six on Roux-en-Y gastric bypass (RYGB), eight on one anastomosis gastric bypass (OAGB), three on single anastomosis duodeno-ileal bypass (SADI) and one duodenal switch (DS). All techniques resulted in weight loss (Fig. 1). OAGB was most effective. Pooled BMI at revision was 41,78 kg/m2 (95% CI, 40.53—43.02) and reduction was 11.48 kg/m2 (95% CI, 8.03—14.92), 14.43 kg/m2 (95% CI, -33.17—62.02), 12.74 kg/m2 (95% CI, -0.94—26.42) and 17.80 kg/m2 (95% CI, 16.33—19.27) after 12, 24, 36 and > 48 months, respectively. OAGB was a relatively safe procedure with an incidence of major complications of 4.5% including 1.2% anastomotic leakage and minor complications in 2.3%. Endoscopic procedure were least effective but showed low complications rates. All other procedures were feasible but differed regarding complication rates. SADI and DS were associated with high complication rates.

Although our data suggest that revisional OAGB was the most effective procedure, Heterogeneity and poor follow-up rates precludes strong conclusions and clinical decision making. Controlled prospective trials with longer follow-up are needed in order to choose the best revisional treatment for long-term success. Choice of procedure is depending on patient’s characteristics and surgeons’ expertise.

AMAZING TECHNOLOGIES

P280—Two port Laparoscopic Trans-Fascial Cutaneo-apponeurotic repair of Ventral hernia with Diastasis of recti in overweight and obese patients. a randomized controlled study.

Bassem Sieda

¹Zagazig University Hospitals, Laparoscopic Surgery, Egypt

Background. Obese Patients with ventral hernia and/or diastasis can be offered a laparoscopic repair even with large defect with better outcome when compared with conventional repair.

Objective. Validating the short and long-term outcomes of laparoscopic trans-fascial repair for ventral hernia with and without diastasis of recti in overweight and obese patients.

Patients and methods. A randomized controlled multi centers study involved a total of 181 overweight and obese patients. BMI ranged from 28 kg/m to 39 kg/m2. Patients were divided into two groups. Group I is the controlled group included patients underwent conventional surgery using onlay PROLENE® Polypropylene Mesh.

Group II underwent Laparoscopic Trans-fascial repair using PDS Loop sutures in midline sequential parity manner with intraperitoneal onlay dual composite mesh. Univariate and multivariate analysis was performed to compare the two groups for early and late postoperative morbidity, Patients were followed for 12 months.

Results: Using visual analogue scale, Group I had more pain than group II from first till 6th postoperative day with significant statistical difference. Patients underwent conventional method manifested more wound complications (seroma and hematoma). Surgical site infection encountered more in group I.

Early recurrence was recorded with very low incidence in group II but no significant statistical difference between the two groups in Late recurrence.

We enrolled high Incidence of ileus and longer hospital stay in group I with peculiar statistical difference.

Conclusion: Laparoscopic sequential cutaneo-apponeurotic Trans-fascial closure repair of Diastasis with ventral hernia is a discriminatory and simple technique no matter what defect size is. The technique averts the formidable wound complication in open surgery.

AMAZING TECHNOLOGIES

P282—Laparoscopic and robotic radical surgery for liver alveolar echinococcosis (echinococcus multilocularis)

Natalia Elizarova, M. Efanov, A. Alikhanov, Y. Kulezneva, O. Melekhina, I. Kazakov, A. Vankovich

¹The Loginov Moscow Clinical Scientific Center, HPB Surgery Department, Russia

Aim. To estimate the immediate and long-term results of laparoscopic and robotic radical surgery for liver alveolar echinococcosis (AE).

Methods: From 2013 to 2019, at the Hepatopancreatobiliary Surgery Department of the Loginov Moscow Clinical Scientific Centre 6 patients with AE were undergone radically surgery using minimally invasive technologies. In 5 cases, a laparoscopic liver resection was performed, and in one case a Da’Vinci robotic complex was used. In all cases a mass was found in the right lobe of the liver, mainly 7–8 liver segments. The average lesion size was 60 ± 20 mm.

Results: In three cases (50%) patients with P2 stage of the disease were operated on, in 3 cases with P1. In two cases, in patients with stage P2, a right hemihepatectomy was performed, in 2 cases a segmentectomy 8 with atypical resection segment 4 was performed, in one case a posterior sectionectomy was performed, in one case the intervention was performed with atypical resection of 6 segments. The average age of the patients was 55 years (27–79), three women and three men (1: 1). In 2 cases patients had previous abdominal surgery. The mean operation time was 344 ± 141 min, the average blood loss was 350 ± 333 ml. An intermittent Pringle maneuvre was used in 4 cases (66,7%) with average ligament clamping time 19 min and with pauses of at least 5 min. Complications were observed in one case (16,7%), type II according to Clavien-Dindo, represented by dynamic intestinal obstruction, which developed on the 6th day of the postoperative period and was resolved conservatively. Mean hospital stay was 9 ± 3. In all cases, there was histological confirmation of the diagnosis by the results of a study of a remote lesion. The average observation time was 45,4 months (10–84).

Conclusion: Laparoscopic and robotic liver resections in the radical treatment of alveococcosis can be safe and feasible in the early stages of alveococcosis (P1-2H0M0), provided they are performed in a specialized hospital with sufficient technical equipment and an experienced surgeon.

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P283—The 3D printing of the specimens required in Intraoperative Ultrasound training

Calin Tiu, E. Elisei², O. Octavia¹, A. Alex¹, V. Tiu¹

¹Medis Foundation, Research, Romania, ²Bistrita Emergency County Hospital, Surgery, Romania

Aim: The acquisition of technical skills in any training process depends decisively on the ability of simulation solutions to reproduce pathological conditions equivalent to real clinical situations. It is obvious that the offer for training of normal situations is much more generous than for acquiring the ability to solve pathological entities, including emergencies.

Material and Method: The same applies to the EAES Ultrasound Course for surgeons, launched six years ago in Frankfurt. Appealing to the human model or to different varieties of molds and phantoms, the teaching and practice of the normal is well supported. However, the pathological entities are presented in graphic and video format, without the possibility of practicing the hands-on maneuvers. As a first step in overcoming these shortcomings, the course team used the construction of 3D printing shells equivalent to the surface of the liver and breast. In these forms are prepared structures equivalent to the two organs using substances such as food gelatin or flour (Figs. 1 and 2).

Results: Equivalents of some normal or pathological anatomical structures obtained by embedding in food gelatin some manually shaped elements could be used for vascular or ganglion puncture exercises, biopsy sampling, dissection plan delimitations, drainage installation.

The European project MIREIA aims to create a software for spatial reconstruction of normal or pathological anatomical structures starting from the imaging associated with that case. Specimens of didactic interest can be exported as a link to interested training centers where they will be 3D printed. This technique will lead to a wide access to models that reproduce pathological situations, with high didactic interest.

Conclusions: The results of the European MIREIA project are expected to produce important qualitative changes in various forms of training in Minimal Invasive Surgery but also in applications such as the EAES hands-on course on Ultrasound for Surgeons.

P284—Gesture Control and Mixed Reality-Based Holographic Monitor for Minimally Invasive Surgical Assistance

Juan A. Sánchez-Margallo, C. Plaza de Miguel, F.M. Sánchez-Margallo

¹Jesús Usón Minimally Invasive Surgery Centre, Bioengineering and Health Technologies Unit, Spain.

Objectives: To present and evaluate a set of tools for assistance in minimally invasive surgery: (1) a gesture control system for interaction with preoperative studies and (2) a mixed reality-based head-mounted display for laparoscopic surgery.

Materials and methods: The gesture control system consists of a wireless gesture recognition system (Myo armband) that together with the TEDCUBE system (TedCas) allows interaction with preoperative studies remotely and aseptically. Two expert surgeons evaluated its use during the performance of several laparoscopic procedures in a porcine model. During the intervention, they used the system to interact with different types of preoperative information. Additionally, a mixed reality-based application was developed as an auxiliary laparoscopic monitor. The experience with the use of this application was evaluated by sixteen surgeons with different levels of experience during the performance of an eye-hand coordination task on a laparoscopic box trainer.

Results: During the interventions, the gesture control system allowed surgeons to interact with CT and ultrasound studies, as well as with the 3D reconstruction of preoperative models. The surgeons found the system to be a useful, simple and safe tool during surgery. They indicated that they would choose this system as a method for interacting with the patient's preoperative information during surgery, although the accuracy of some gesture control maneuvers would need to be improved beforehand. Regarding the application of the auxiliary monitor for laparoscopic surgery using mixed reality, the participant surgeons completed all the tasks within the maximum time established (300 s). Most of them rated positively the effectiveness of using the application in laparoscopic practice. However, they considered the image sharpness and color as aspects that could be improved.

Conclusions: The gesture control system provides an intuitive interface for interaction with preoperative information during surgery while maintaining the surgeon's aseptic conditions. However, it is necessary to improve its accuracy prior to use in real surgical environments. Participating surgeons reported a positive experience using the mixed reality-based holographic monitor, indicating that they could perform more complex laparoscopic tasks and procedures.

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P285—Measurement of Surgical Knot Failure Forces: Design and Validation

Masie Rahimi ¹ , J.W. Klok², S.F. Hardon¹, H.J. Bonjer¹, J. Dankelman³, F. Daams⁴, T. Horeman-Franse²

¹Amsterdam UMC/ Amsterdam Skills Centre, Surgery, The Netherlands, ²Delft University of Technology, Department of BioMechanical Engineering, The Netherlands, ³Delft University of Technology, Department of BioMechanical Engineering/Faculty of Mechanical, Maritime and Materials Engineering (3 mE), The Netherlands, ⁴Amsterdam UMC, Surgery, The Netherlands

Aims: Surgical wound suturing and open surgical knot tying are essential basic surgical skills. Wound healing after suturing heavily relies on the quality of the suture and strength of the surgical knot. For an efficient training curriculum, with a high learning efficiency, an appropriate objective assessment with feedback is also paramount. To assess the quality of a surgical suture, a new and user friendly knot testing tool was developed and tested.

Methods. A new pinned “Hook in Force Measuring (HFM)” device was created to test and evaluate surgical sutures. The pins of the HFM were hooked underneath the surgical suture and spread until the knot started to slip (Fig. 1A). The force sensor in the HFM consisted of a spring steel sheet, enabling the handle to deform elastically when the pliers were used to open the suture. The amount of deformation was proportional to the load needed to open the suture. The deformation is measured by a hall sensor and permanent magnet combination. In addition, the HFM opening angle α is measured using a potentiometer (Fig. 1).

After calibration with free weights and a calibre, the HFM device was tested on 3 surgical suture knots performed by an experienced surgeon. Surgical suture 1 was made according to the standards but not tightened, suture 2 was made according to the standard and tightened at the end and suture 3 was made loosely and not tightened at all. Using the force and angle data, the input energy until knot failure E was determined by calculating the integral of the moment arm (M = Fd) over the pliers opening angle α with F being the opening force as a function of α and d was the moment arm.

E = ∫Fd dα.

Results/discussion: The surgeon had no problem using the tool and was able to test the 3 sutures within a minute. Figure 2 showed the force-angle relation of the 3 measured suture knots. It becomes clear from the data that surgical suture 3 showed the most slip, surgical suture 2 started to unraffle and surgical suture 1 showed an increase in angle opening resulting in a higher loop force. The instance of knot failure is defined as the point where the maximum force occurs and is denoted with an asterisk. The input energy until knot failure was 0.26 J, 0.31 J, and 0.70 J for surgical suture 1, 2 and 3 respectively.

Conclusions: The HFM proved to be an user friendly and useful tool to measure knot dynamics, failure force and input energy. The maximum force can be used in suture knot quality assessment and training of basic suturing skills.

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P286—Diagnostic Accuracy of 3D-based AI Technology to Identify the Status of the Predicted Resection in Margins in Patients with Locally Advanced and Recurrent Rectal Cancer

Gianluca Pellino ¹ , G. Pellino¹, S. Jerí Mc Farlane², A. García-Granero², J. Sancho Muriel³, V. Primo Romaguera³, B. Flor Lorente³, M. Gamundi Cuesta², F.X. Gonzalez Argente²

¹Università degli Studi della Campania Luigi Vanvitelli, Department of Advanced Medical and Surgical Sciences, Italy, ²Hospital Universitario Son Espases, Spain, ³Hospital Universitario y Politécnico la Fe, Spain.

Background: R0 or tumour-free surgical margins resection represents the strongest prognosticator of survival in locally advanced primary (LAPRC) and locally recurrent rectal cancer (LRRC). Magnetic resonance imaging (MRI) is the technique of choice to assess the infiltration of surrounding structures, currently representing the ideal tool for preoperative planning. In LAPRC, MRI negative predictive value of infiltration is reported to be 94%, however, a 54% positive predictive value has been estimated. In addition, diagnostic accuracy of MRI might not exceed 60% in LRRC.

Aim. The aim of this study was to assess the usefulness of a three-dimensional image processing and reconstruction (3D-IPR) model to achieve R0 resections and to compare the diagnostic accuracy between MRI and 3D-IPR regarding the infiltration of surrounding structures in LAPRC and LRRC.

Materials and Method This is a prospective study performed at two referral centres for rectal cancer between January 2020 and January 2022. 3D-IPR was applied to MRI of patients with LAPRC or LRRC, before surgery. The MRI findings were compared with those of 3D-IPR, focusing on predicted surgical margins. The standard of reference was definitive pathology of the specimen.

Results: Twelve patients were evaluated (7 LAPRC and 5 LRRC). A complete agreement between MRI and 3D-IPR was observed in 16% of cases (examples provided in Figs. 1, 2). One patient received anterior resection of the rectum, 4 en bloc rectal resection extended to surrounding structures, and 7 pelvic exenteration; 75% of specimens were classified as R0. The diagnostic accuracy was 33% for MRI and 91% for 3D-IPR.

Conclusions: The 3D-IPR method can be useful to improve diagnostic accuracy of MRI scans in assessing the relationship with surrounding structures in patients with LAPRC and LRRC.

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P287—Threatened Retroperitoneal Margin in Right Colon Cancer. Preoperative Assesment Through 3D-Reconstruction Mathematical Model

Sebastian Jeri-McFarlane ¹, G. Pellino², A. Garcia-Granero¹, J. Sancho-Muriel³, A. Gil-Catalan¹, F. Giner⁴, I. Amengual⁵, M. Martinez⁵, M. Gamundi-Cuesta¹, F.X. Gonzalez-Argente¹

¹Hospital Universitario Son Espases, General, Spain, ²Hospital de Vall D'Hebron, General & Digestive Surgery, Spain, ³Hospital Universitario y Politecnico La Fe, General & Digestive Surgery, Spain, ⁴Hospital Universitario y Politecnico la Fe, Pathology, Spain, ⁵Hospital Universitario Son Espases, Pathology, Spain

Introduction and Objetives: The retroperitoneal margin infiltration in oncological right colectomy has been related to augmented risk of locoregional recurrence and decrease in survival rates.

Surgeon’s knowledge of the embryological development is basic to obtain free surgical margins (R0) in right colon tumors with threatened retroperitoneal margin (TRM) in preoperative imaging.

However, the specificity of preoperative computed tomography (CT scan) to evaluate the local extension of colon cancer is about 60%.

The objective of this study is to show the utility of a 3D reconstruction mathematical model (3DMM) to obtain R0 surgeries in TRM tumors in right colon cancer.

Materials and methods: Applying a 3DMM to evaluate TRM in three real cases of right colon cancer.

Phase 1: development of a mathematical algorithm in a retrospective manner in two cases with right colon cancer and known TRM in CT scan. Development from concluded anatomic-pathology report (APR).

Phase 2: Prospective application of mathematical algorithm developed in phase 1 in a real case of right colon cancer with TRM in CT scan. Comparing CT scan report and 3DMM from the anatomic-pathology report.

Results:

Phase 1:

Patient 1: Ascending colon neoplasm with suspicion of duodenal infiltration in CT scan. Right colectomy was performed without duodenal resection due to intraoperative findings. APR showed free retroperitoneal margin with a distance of the tumor to retroperitoneal margin of 4 mm. Retrospective 3DMM showed a minimum distance from the tumor to the duodenum of 6.24 mm and 9.8 mm to the pancreas.

Patient 2: Ascending colon neoplasm without suspicion of duodenal infiltration in CT scan. Right colectomy was performed extending resection to the duodenal flexure due to intraoperative findings. APR confirmed duodenal infiltration. Retrospective 3DMM showed duodenal infiltration with an infiltration volume of 0.4 mm.

Phase 2: Patient with ascending colon tumor with doubt of anterior renal fat infiltration in CT scan. Prospective 3DMM ruled out retroperitoneal infiltration (distance from tumor to retroperitoneal fascia of 0.1 mm). En bloc right colectomy was performed extending resection to retroperitoneal fascia and retroperitoneal fat. APR discarded retroperitoneal fascia and fat infiltration. R0 resection.

Conclusions: A 3D reconstruction mathematical model can useful to evaluate tumor infiltration of the retroperitoneal margin in right colon cancer. This preoperative tool may help in the surgical strategy to obtain R0 oncological resections.

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P288—Surgical Strategy Based on 3d Reconstruction & Artificial Intelligence for Complex Fistulas in Crohn’s Disease: Pilot Study

Sebastian Jeri-McFarlane ¹, G. Pellino², A. Garcia-Granero¹, A. Ochogavia-Segui¹, A. Oseira-Reigosa¹, A. Gil-Catalan¹, D. Guinard³, M. Gamundi-Cuesta¹, F.X. Gonzalez-Argente¹

¹Hospital Universitario Son Espases, General & Digestive Surgery, Spain, ²Hospital de Vall D'Hebron, General & Digestive Surgery, Spain, ³Hospital Universitario Son Espases, Gastroenterology, Spain

Introduction: European Crohn’s and Colitis Organization (ECCO) guidelines propose that the key treatment of perineal Crohn’s disease (PCD) is abscess drainage and tutoring of fistula with setons. However, 80% of fistulas in these cases are considered as complex with up to 20% requiring more than two surgical procedures to accomplish these objectives. Endoanal ultrasonography and magnetic resonance images (MRI) are the gold standard as preoperative techniques. Nevertheless, both techniques present specificity values of 80% to detect main fistula tracts and internal fistula orifices (IFO).

The objective of this study is to evaluate the utility of a 3D reconstruction mathematical model (3DMM) for the surgical strategy in PCD as wells as its capacity to locate abscess, identifying possible IFO and fistula tracts.

Materials and methods: Two phase study:

Phase 1: analysis of diagnosed patients with PCD in a reference colorectal unit. Assessment of patients current status and the number of necessary surgical procedures to achieve complete abscess drainage and tutoring of fistula tracts.

Phase 2: Evaluate the utility of 3DMM from MRI in patients considered as non-resolved during phase 1. The success assessment was done with post-operative MRI.

Results: Phase 1: 34 patients were analyzed. The number of mean surgical procedures was of 3.8 per patient. The mean number of interventions to achieve IFO localization was of 2.8. The percentage of fistulas considered as non-resolved was of 70% with a mean surgical procedures of 4.2.

Phase 2: 3DMM were applied in 4 patients. All of them achieved drainage of abscess zones and IFO located as well as primary and secondary tracts tutored in only one surgical procedure.

Conclusions: A 3D reconstruction mathematical method may be useful for the surgical strategy in patients with perineal Crohn’s Disease. This is to decrease the number of procedures needed to drain completely septic fluid collections and locating possible IFO´s and fistula tracts.

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P289—Advancement in Technology and its Benefits in Gastrointestinal Stromal Tumours Resections

Madhu Chaudhury, C. Ball, V. Shetty, J. Ward, P.D. Turner, K.G. Pursnani

¹Royal Preston Hospital, Lancashire Teaching Hospital Trust, Upper GI Services, General Surgery, United Kingdom

Aim: Our unit has been involved in removing Gastrointestinal stromal tumours (GISTs) for over 10 years. Recent technological advances and the inception of Robotic surgery has allowed us to achieve difficult local excisions successfully which would otherwise prove challenging. With the development of robotic surgery, the DaVinci robot has allowed the surgeon to perform precise wedge resection with high definition 3D visualisation and instruments with endowrist technology. This study was to see the difference in Length of Stay (LoS) comparing the three different techniques which includes Open vs Laparoscopic vs Robotic.

Methods: We looked at case notes retrospectively of all the gastric GISTs excised from 2011–2021. The database comprised of open, laparoscopic and robotic cases amongst 5 surgeons. Where case notes were unavailable, those were removed from data collection. LoS of the complete hospital admission was observed between the different techniques, open vs laparoscopic vs robotic. This was statistically assessed using Mann–Whitney U test on SPSS v22.

Results: We performed 88 GIST resection cases. 19 (22%) cases were open, 61(69%) cases were laparoscopic and 8 (9%) cases were robotic in our Upper GI unit. The median age of the patients was 59 (range 48–82) years. The median LoS for Open was 9 (range 5–19) days, for laparoscopic it was 7 (range 5–12) days and for robotic 5 (range 2–9) days. Our data suggested significant difference in the LoS between the 3 groups. Tumour negative margins were accomplished in all case notes reviewed. The table attached shows the p-values.

Conclusion: Our data shows that with the advent of robotic technology, there is a significant reduction in the total LoS between the different techniques. In addition, our robotic surgery data suggests gastric GIST can be removed successfully from challenging anatomical locations avoiding radical excision such as gastrectomy. This may help reduce the need for HDU admission and improves functional outcome.

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P290—Human Subject’s Study for Virtual Fixtures Tools Collision Avoidance Evaluation in Robotic Surgery

Cristina Iacono, R.M. Moccia, F.F. Ficuciello

¹Università degli Studi di Napoli Federico II, Department of Electrical Engineering and Information Technology, Italy

Aims: During robot-assisted surgical procedures using the dVRK robot, potential collisions between surgical tools could create issues for the surgeons. Shared control techniques based on Virtual Fixtures (VF) can be applied to avoid surgical tool clashing, by rendering a repulsive force to the surgeon which is inversely proportional to the distance between tools. This work presents a human subjects’ study, that aims to demonstrates significant performance improvements thanks to the surgeon’s haptic feedback.

Methods: The study involves twelve subjects divided into two groups, six experienced and six novice surgeons. It is articulated in two experiments using the dVRK robot in teleoperation mode. During each test, the subject keeps the first tool centered in the middle of a circle; meanwhile, the second tool must follow the circular path for 270◦ from a definite starting point 5 times. The test is performed both in free motion and with a VF collision avoidance method.

Results: Figures 1 and 2 show the mean values of the minimum distance between tools for novice and expert subjects during both tests. To demonstrate the statistical relevance, a comparison is made between the mean values of minimum distance, through a statistical unpaired t-test, with a significance level α = 0.05. The test shows statistically significant differences between the means for all subjects in the novice group (Table I). It presents an increase in the minimum distance values of ∼ 10% in collision tests compared to free-hand tests.

Conclusions: The human subject study has shown statistically significant differences between the mean of the minimum distance between tools for the novice subjects. The VF test outperformed the free-hand test of 75%. No statistically significant differences are reported for expert surgeons. This result suggests that feeling a haptic force during the task allows maintaining a safe distance between the surgical tools. On the contrary, in the free-hand test, the subject has no force feedback and could dangerously reduce the distance between the tools. The results suggest that the VF-constrained task is not mentally or physically demanding. It represents a comfortable reminder of the collision risk, that diminishes the surgeon's mental workload.

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P291—Use of the TI-Knot device is safe, faster, and easier alternative to the hand-tying in the repair of the large hiatal defect

Milos Bjelovic¹

¹Euromedik Hospital, Department of Surgery, Serbia.

There are two main technical causes of recurrent hiatal hernia: unrecognized secondary short esophagus and insufficient hiatal closure. Primary posterior or retroesophageal cruroraphy has been the mainstay of practice for many years in hiatal hernia repair. To avoid tension on the suture line in cases of a large or round-shaped hiatal defect, in mixed (type III) and in giant PEHs, plication of the left pillar should be performed. The aim of this widely accepted technique is to loosen the tension on the pillars as much as possible. Nevertheless, in the case of the fibrotic crura, or significant bowing of the left pillar, tension is a real issue and hand tying could be challenging and cause additional tissue damage.

The Ti-KNOT Device (LSI SOLUTIONS®, Victor, New York) offers an atraumatic, safe, and potentially faster and easier alternative to hand-tying.. Its strength, security, and reliability have been previously confirmed in different laparoscopic procedures, including hiatal closure. Back in 2003, Davis R described the technique where the crural defect was closed using interrupted 0 Ethibond sutures and secured with the Ti-KNOT. In 2017, Banki F published experience with the use of Ti-KNOT in hiatal hernia repair on more than 200 cases.

The Ti-KNOT has a shaft5 mm in diameter and 31 cm in length, which is optimized for remote suture fastening during minimally invasive procedures. An ergonomic lever enables surgeons to crimp the Ti-KNOT titanium fastener while trimming and cutting the suture, all in one easy squeeze (one squeeze technology). It has been available and in standard use in the US market for many years; CE mark approval was granted recently. It’s expected that the use of Ti-KNOT will be cost-effective compared to hand tying hiatal closure, but this has to be proven with large-scale randomized control trials.

In conclusion, The Ti-KNOT Device offers an atraumatic, safe, and potentially faster and easier alternative to hand-tying. Its strength, security, and reliability were previously confirmed in different laparoscopic procedures, including difficult hiatal closure.

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P292—Implementation Of Intraoperative Colonoscopy (IOC) for Diagnosis of Modern Gunshot Colon Penetrating Wounds at the Role 2 of Medical Support

Oksana Popova ¹ , K. Gumeniuk²

¹MilitaryMedical Clinical Center of Eastern Region, Surgery, Ukraine, ²Medical Forces Command of Ukrainian Armed Forces, Ukraine

Introduction. Gunshot wounds of the colon are the most severe injuries of the abdominal cavity and are characterized by a large number of complications and high mortality, it is about 26.7%. In modern conditions, the problem of diagnosis gunshot wounds of the colon remains relevant, especially its mesoperitoneal part, when during laparotomy it is impossible to diagnose minor penetrating injuries (grades 1–2 according to AAST). With untimely diagnosis, such injuries in the postoperative period causes to severe and often fatal infection complications.

The aim is to improve the diagnosis of gunshot penetrating injuries of the colon in the wounded by using IOC at the Role 2 of military medical support.

Methods: At the Role 2 of medical support in military mobile hospitals located in the area of Operations of the Joint Forces at the East of Ukraine, 208 servicemen with gunshot penetrating wounds to the abdomen with damage to the colon were examined and operated on. The age of the wounded was from 18 to 55 years, on average (33.2 ± 8.8). The presence of hemoperitoneum, subtly and thickly intestinal contents made it difficult to determine the topic of damage, so intraoperative colonoscopy was performed. Surgeon controlled the passage of the colonoscope through the parts of the intestine, air supply, luminescence and blood detection in the colon, which helped to quickly visualize the places of penetrating damage. Intraoperatively, these wounded were diagnosed with multiple gunshot shrapnel wounds of the colon of the 1–2 degrees according to AAST.

Results: IOC allowed to quickly and accurately establish the topographic and anatomical location of penetrating lesions in all 19 (9,1%) cases, in another 7 cases (not included to the group) it allowed to exclude damage to the colon. Injuries were distributed by localization as follows: cecum—0, ascending part colon—3 (15.85%), hepatic angle—4 (21%), transverse colon—3 (15.85%), splenic angle—1 (5.3%), descending colon—4 (21%), sigmoid colon—4 (21%). Through wounds were found in 18 wounded (94.7%), blunt with a metal fragment inside the colon—in 1 (5.3%) case.

Conclusions. Performing intraoperative colonoscopy in wounded with gunshot wounds penetrated the abdomen in 19 (9.1%) cases allowed to clearly and quickly verify the damage to the colon and to establish the topographic and anatomical location of injuries, especially difficult to diagnose parts of the colon. In 7 cases (not included in the group) IOC allowed to exclude the damage to the colon. Visualization of multiple small lesions prevented the development of severe complications in the postoperative period. In 1 (5.3%) case, intraoperative colonoscopy allowed to remove a metal fragment from the colon during surgery. Intraoperative colonoscopy can be used for diagnose wounds with colon damage at the Role 2 of medical care—in military-mobile hospitals for rapid diagnosis of colon damage and their location, as well as prevention of complications associated with late diagnosis.

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P293—The Value of Collision Feedback In Robotic Surgical Skills Training on the PoLaRS system

Sem Hardon ¹, R. Postema¹, M. Rahimi¹, T. Horeman², F. Nickel³, J. Dankelman², A. Bloemendaal⁴, M. van der Elst¹, D. van der Peet¹, F. Daams¹

¹Amsterdam UMC—VU University Medical Center, Surgery, The Netherlands, ²Delft University of Technology, Biomechanical Engineering, The Netherlands, ³Heidelberg University, General, Visceral and Transplantation Surgery, Germany, ⁴Reinier de Graaf Gasthuis, Surgery, The Netherlands

Background: Collision feedback about instrument and environment interaction is often lacking in robotic surgery training devices. The PoLaRS virtual reality simulator is a newly developed desk trainer that overcomes drawbacks of existing trainers. We investigated the effect of haptic and visual feedback during training on the performance of a robotic surgical task.

Methods: Robotic assisted surgery-naïve participants were randomized and equally divided into two training groups: Haptic and Visual Feedback (HVF) and No Feedback (NF). Participants performed two basic virtual reality training tasks on the PoLaRS system as a pre- and post-test. The measurement parameters Time, Tip-to-tip distance, Path length Left/Right and Collisions Left/Right were used to analyze the learning curves and statistically compare the pre- and post-tests performances.

Results: In total, 198 trials performed by 22 participants were included. The visual and haptic feedback did not negatively influence the time to complete the tasks. Although no improvement in skill was observed between pre- and post-tests, the mean rank of the number of collisions of the right grasper (dominant hand) was significantly lower in the HVF feedback group during the second post-test (Mean Rank = 8.73 versus Mean Rank = 14.27, U = 30.00) p = 0.045).

Conclusion: Haptic and visual feedback during the training of robotic surgery skills on the PoLaRS system result in fewer instrument collisions. Differences in hand-dominance indicate the value of additional training. The PoLaRS system can be utilized to remotely optimize instrument handling before commencing robotic surgery in the operating room.

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P294—Controlling a Collaborative Robot with a Depth Camera using the IEEE 11,073 SDC Communication Standard

Johann Berger, M. Unger, T.A. Wahl, A. Melzer

¹University Hospital Leipzig, Innovation Center Computer Assisted Surgery, Germany

Purpose. The benefits of robotic systems in image-guided interventions are widely known. Due to the high complexity of robotic workflows, the acceptance of active robots in the clinic still lacks behind. Natural user interaction principles and the possibility of easy system integration are the main concern in modern medical robotics. A variety of tools like position sensors and standardized communication protocols for medical devices was published in the last 5—10 years. Utilizing these tools efficiently can provide the missing link between user-friendly interaction and robotic precision. In this work, we present the integration of an established infrared position sensor with a collaborative robotic system for ultrasound-guided interventions, e.g., needle biopsies and focused ultrasound ablations. This setup shows the feasibility of a fast and intuitive integration of optical sensors with robotic systems for motion control procedures.

Methods and Materials. To integrate a Kinect V2 body sensor (MICROSOFT, USA) with a KUKA LBR iiwa 7 R800 robot (KUKA AG, Germany) both systems were implemented as IEEE 11,073 SDC conform virtual medical devices to share position information and control rights via network. The Kinect inherent body-stream served to perform movements with a Clarius L7 wireless ultrasound device (Clarius Mobile Health Corp., Canada) between pre-defined target positions and the user's hand. An NDI Polaris Vega tracking camera (Northern Digital Inc, Canada) provided the shared coordinate system for an initial co-registration of both devices with a basic 3-point landmark approach. The system was tested by performing 20 movement repetitions for 2 different setup configurations.

Results: The system provides a stable and repeatable interaction between all co-registered devices while communicating via the SDC standard. In all performed commands the robotic system behaved as expected and the target positions provided by the Kinect sensor were reached successfully.

Conclusion: The implemented control system shows the feasibility of integrating different sensor devices in a standardized fashion. The setup of a Kinect V2, a Polaris Vega, and a KUKA robotic arm constitutes a proof of concept for straightforward augmentation of surgical robotics to provide novel interaction concepts. The presented system cannot support real-time critical events yet and must be further tested. The utilized landmark registration must be assessed to isolate possible accuracies and limitations. By providing a standardized method to integrate imaging robotics with position sensors, higher usability can be achieved for existing and new robots to perform, e.g., ultrasound-guided needle biopsies and focused ultrasound ablations.

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P295—The Application of Computer Vision Technologies to Track Patterns on Ultrasound Video Footage for Medical Robots’ Navigation

Dmitry Panchenkov ¹ , D.D. Klimov², Yu.V Poduraev³, A.A. Levin², A.G. Nosova⁴, A.A. Nechunaev¹, L.S. Prokhorenko², D.S. Mishchenkov²

¹Moscow State University of Medicine and Dentistry, Surgery and Surgical Technoligies, Russia, ²Moscow State University of Medicine and Dentistry, Medical Robotics, Russia, ³Moscow State University of Technology STANKIN, Robotic Technologies, Russia, ⁴Moscow State University of Medicine and Dentistry, Radiology, Russia

Aims. Electrode positioning during radiofrequency ablation of internal organs neoplasms or needle positioning for biopsy is a challenging and time-consuming task on which the result of diagnosis and treatment depends. And in the case of using robotic-assisted systems, the technical complexity associated with intraoperative position determination of the tumor also manifests itself.

Methods: To solve this problem with the help of modern technologies it is proposed to use the existing techniques and methods of computer vision. This process is more complicated because of low image resolution, the absence of a color component and overall noisiness.

Based on the assumption that the tracked object occupies the main part of the image in the desired area, it becomes possible to highlight it on the image with a certain color, which should simplify the perception of the ultrasound image.

The specifics of working with ultrasonic video images also made it possible to apply several optimizations, which decreased frame processing time. Since the velocity of the neoplasm is limited from above by some reasonable value, it is possible to restrict the search area on the next frame. Several parameters like velocity, position, and frame rate are being considered.

Results: Thus, in the final system, it is proposed to use more than ten algorithms that allow tracking neoplasms and other structures of internal organs. Combining them is possible with different weighting factors. Additional testing of this system prototype showed the possibility of using it to track patterns that are visually distinguished on the ultrasound image, such as neoplasms, tumors, cysts, and vessels.

Conclusion: This technique can achieve a performance of up to 40–90 frames per second with a tracking accuracy exceeding 90%, which will allow real-time transmission of the coordinates of the neoplasm to the navigation system of the robotic-assisted systems while highlighting various patient structures with colors for convenience of medical staff.

AMAZING TECHNOLOGIES

P296—3D printing technology applied to minimally invasive surgery training

Juan A. Sánchez-Margallo ¹ , J.B. Pagador Carrasco¹, C. Plaza de Miguel², D. Patrocinio Caballero¹, V.P. Galván Chacón¹, D. Durán Rey³, F.M. Sánchez-Margallo⁴

¹Jesús Usón Minimally Invasive Surgery Centre, Bioengineering and Health Technologies Unit, Spain, ²Jesús Usón Minimally Invasive Surgery Centre, TREMIRS Unit, Spain, ³Jesús Usón Minimally Invasive Surgery Centre, Laparoscopy Unit, Spain, ⁴Jesús Usón Minimally Invasive Surgery Centre, Scientific Direction, Spain

Introduction: Traditional training methods in minimally invasive surgery (MIS) are often based on static learning content and sometimes far from real clinical practice. The MIREIA (Mixed Reality in medical Education based on Interactive Applications) project is an Alliance that aims to combine the use of cutting-edge technology in immersive virtual technology and 3D printing with personalized learning content to promote a student-centered learning process. As part of this project, the objective of this study is to analyze the state of the art of 3D printing technology for its application in MIS training.

Materials and Methods: A structured bibliographical search was conducted in the PubMed database. The applications of 3D printing were organized into two main groups: (1) as a training method in medical and surgical anatomy and (2) as a physical model for training basic surgical skills in a laparoscopic training simulator. From the studies obtained, aspects such as materials, equipment, pre- and post-processing methods, and printing techniques, were analyzed.

Results: A total of 272 articles were considered for this study, of which 95 articles were finally selected. Neurosurgery, otolaryngology and urology were the surgical specialties that have shown the greatest application of 3D printed models for training. The skull was the most popular 3D printed structure for training in neurosurgery and otolaryngology. Other common structures were the head and neck for otolaryngology and the kidneys and urinary system for urology training. The most widely used fabrication technique was Fused Deposition Modeling, followed by ColorJet Printing. Stereolithography was also used in about one in ten articles, mainly because of its higher resolution. Selective Laser Sintering was used in about one in twenty papers, due to its excellent resolution and mechanical properties of the resulting parts. Once the 3D model is obtained from the preoperative imaging study, post-processing is carried out to clean, smooth and adapt the model to the specific application. The most popular software for this purpose were Meshmixer and Materialise 3-Matic (Materialise NV). As for software for 3D printing preparation, the most popular was Ultimaker Cura (Ultimaker B.V.). Of the most commonly used 3D printers, we highlight equipment from Stratasys, 3D Systems, Ultimaker and Formlabs. Regarding the model validation methods used, most of them relied on subjective surveys and objective metrics to establish the similarity of the printed model to the actual anatomy.

Conclusions: This study revealed a variety of techniques and materials used to produce 3D models for MIS training. In general, 3D printed training models can belong to two domains, on the one hand models for anatomical learning (anatomical models), and on the other hand models for practical training (practical models). In order to achieve a suitable training model, two characteristics must be taken into account, on the one hand the fidelity of the model and on the other hand the simulation of the behavior (replication of functional aspects). To create models with both characteristics, a compromise between both characteristics is required.

AMAZING TECHNOLOGIES

P297—Use of 3D printed markers for Mixed Reality-guided maxillofacial surgery

C. Plaza de Miguel¹, Juan Alberto Sánchez-Margallo ¹ , J.A. Sánchez-Margallo², J.C. Moreno Vázquez³, F.M. Sánchez-Margallo²

¹Jesús Usón Minimally Invasive Surgery Centre, TREMIRS Unit, Spain, ²Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain, Bioengineering Unit, Spain, ³Neofacial Institute, Badajoz, Spain, Spain

Introduction: The use of Mixed Reality (MR) wearable devices such as the HoloLens 2 (Microsoft) together with Vuforia's computer vision libraries allow the development of image-guided surgery applications on bony structures, such as maxillofacial surgeries. In the past, augmented reality libraries required a two-dimensional 83D) marker such as a QR or a pre-trained image, but nowadays these libraries allow the use of three-dimensional markers. This fact opens up a multitude of possibilities in terms of the fabrication of 3D markers due to the rapid spread of the use of 3D printing.

Materials and methods: A series of markers with different angles, shapes and colors have been manufactured and tested for its use in image-guided maxillofacial surgery, finally arriving at the visual marker presented. This marker has been printed with the i3 MK3 3D printer (Prusa) using polylactic acid (PLA) material in two colors easily distinguishable visually: red and black (Fig. 1A). This printed visual marker has been trained using a training set of the Model Target Generator tool (Vuforia) and integrated in an application for Universal Windows Platform developed with the Unity 3D engine (Unity Technologies) using the MixedRealityToolKit libraries. Within this 3D-printed marker, three radiopaque fiducial markers (GoldAnchor) have been embedded. These markers will be used to register the preoperative 3D model of the patient with the visual marker using MR during surgery. To test the feasibility of using these fiducial markers, they have been analyzed by computed tomography (CT) (Fig. 1B) and fluoroscopy (Fig. 1C and D). Finally, the registration by means of MR of the different anatomical elements obtained from a CT scan together with the implants provides the surgical planner for maxillofacial implants (Fig. 1E).

Results: A proof of concept using this MR-based registration system has been successfully conducted using a phantom for maxillofacial surgery (APB, Frasaco). For use, the surgeon has to direct the gaze towards the 3D printed marker with the MR device (Fig. 2A). Automatically, the system will detect this visual reference marker and superimpose on it in holographic form the 3D model of the bone structure together with the implants to be performed (Fig. 2B). Using an interface that can be interacted with by manual gestures or voice commands, the surgeon will be able to make the bone structure transparent and visualize where to perform the implants (Fig. 2C), obtaining a better spatial perception of the surgical procedure.

Discussion and conclusions: Future work should be carried out to determine the level of accuracy obtained in the identification and real-time tracking of the frame for the registration process, as well as to achieve a fully automatic registration method. Other types of structures such as soft tissues pose more complications of registration in terms of accuracy.

AMAZING TECHNOLOGIES

P298—Fluorescence technology and its role in bariatric surgery

Alessia Fassari, A. Biancucci, M.M. Lirici, S. Lucchese

¹San Giovanni Addolorata Hospital Complex, General Surgery, Italy

Aim: Gastrojejunal and gastric leaks remain an important cause of morbidity and mortality after bariatric procedures (Laparoscopic Sleeve Gastrectomy, LSG; One Anastomosis Gastric Bypass, OAGB; Roux-en-Y gastric bypass, RYGB). Indocyanine Green Fluorescence (IGF) angiography is a recent development to assess tissue perfusion and perform vascular mapping during laparoscopic surgery which may help in preventing ischemia-related leaks.

Materials and Methods: As demonstrated in our video to perform LSG, almost all of the greater curvature blood supply is coagulated and divided, starting just a few centimeters from the pylorus and working cephalad until all the short gastric vessels near the left crus are coagulated and divided. The dissection is carried very close to the angle of His to avoid leaving behind a significant part of the fundus. Sleeve gastrectomy is then performed on a 36-Fr bougie using linear stapler. In the OAGB dissection should be started on the lesser curvature at the crow's foot in order to enter into the lesser sac by carefully freeing posterior adhesion between the stomach and pancreas. Once this is done, the first staple firing is done. The gastric pouch must be lengthy and narrow, measuring around 15–18 cm, with a 50–150 ml reservoir capacity. Unfortunately, anatomic studies have demonstrated that the vascular supply of the upper part of the gastric tube can be damaged during these procedures. Furthermore there are other potential causes of leaks besides ischemia, such as mechanical increase of intragastric pressure in the setting of decreased gastric volume. In certain cases, it may be a combination of both mechanical and ischemic events that leads to a leak. The OAGB is completed with antecolic gastrojejunostomy between the posterior wall of the gastric pouch and the antimesenteric border of the jejunum (approximately 150–200 cm distal to the ligament of Treitz). Once the stomach is resected (case 1) and gastrojejunal anastomosis is performed (case 2) 1,25 mg of indocyanine green solution is injected in a peripheral vein.

Results: A regular and homogeneous perfusion was observed along the entire gastric sleeve including the esophago-gastric junction (LSG) and the gastrojejunal anastomosis (OAGB). On the contrary, the excised specimen appeared devascularized at IGF imaging as expected. Operation time was 30 min for LSG and 40 min for OAGB with negative intraoperative and 2-day postoperative methylene blue test. Patients were discharged on postoperative day 2.

Conclusions: ICG fluorescence is widely used in multiple surgical specialities but has been introduced in bariatric only recently. Our video shows the safety and feasibility of using fluorescent angiography for gastric or gastrojejunal perfusion assessment.

AMAZING TECHNOLOGIES

P299—Evaluation of Peritoneal Particle Escape in a Valve-Less Trocar System

Daniel Robertson ¹ , T. Lenssen¹, Technology Committee of the EAES², T. Horeman¹

¹Delft University of Technology, BioMechanical Engineering, The Netherlands, ²EAES

During the COVID-19 pandemic, laparoscopic surgical procedures were delayed due to the possibility of viral transmission to surgical staff. Although the risk of transmission was shown to be low, surgical staff has become more concerned about of the health impacts of viruses and other particles in peritoneal gas during laparoscopic procedures.

For some surgeons, this concern extended to the Airseal Insufflator System. This is a valve-less trocar system that is promoted to have better pneumo-peritoneal stability and better smoke evacuation. However, due to the lack of valves, it is suspected that peritoneal particles could escape into the surgical workspace.

Aims. Therefore, the aim of this study was compare the number of particles that escape from the Airseal trocar with a conventional trocar using a bench-top setup.

Methods. The setup consisted of two stacked containers with a flexible abdomen phantom to create an airtight seal with the trocars, as seen in Fig. 1. The number of 0.3 µm particles in the containers was measured using a particle counter, a particle generator was used to create sodium chloride salt aerosol particles in the lower box. The number of particles in the lower box remained constant at 8*10^5 particles.

The Airseal Insufflator insufflated the lower container, while connected to the Airseal 12-mm trocar or the conventional 12-mm disposable trocar. Therefore, the only pathway for the particles from the lower to the upper container was through the trocars.

Results: The preliminary results show a higher rate of particle escape when using the Airseal trocar compared to the conventional trocar. During measurements on the Airseal trocar, the number of particles in the upper container increased from 5.5*10^4 to 20*10^4. For the standard trocar, the number of particles increased from 3.4*10^4 to 4.1*10^4.

Conclusion(s): During this study, some influential conditions were tested to measure the trocars’ performance. The next steps are to include additional testing conditions such as pressure differences in the lower container, to simulate patient breathing. Looking at the difference in performance of the trocars, we find that the Airseal trocar is unable to prevent all particles from escaping the peritoneal cavity.

AMAZING TECHNOLOGIES

P300—The SATA-Drive: a 5-DOF robotic driver for the SATA-LRS laparoscopic instrument-line

Tomas Lenssen, J. Dankelman, T. Horeman

¹Delft University of Technology, BioMechanical Engineering, The Netherlands

Introduction: Robot assisted surgery has proven to have high potential for driving complex instruments with additional degree of freedom but that still suffers from residual contamination and limited re-use. The SATA-LRS offers a modular solution focused on cleanability and exchangeability. The SATA-Drive, a robotic driver, is made for the actuation of a 3 mm scaled version of the SATA-LRS, made and used as proof of concept.

Methods: A specific gear mechanism has been designed to efficiently translate motor rotation to linear translation of the shafts. The Drive is used to control the 3 mm instrument in a demonstration using a robotic arm. Eight subjects are included in an user-experiment on the (de)coupling of the instrument on the drive.

Results: The Drive and the 3 mm instrument have been successfully produced. A demonstrative video shows the SATA-Driver successfully control the 3 mm instrument in grasping and steering. The user-experiment shows tip-exchange possible in 33 s, while complete instrument de-coupling requires 28 s.

Discussion: The SATA-Diver is able to sufficiently control the SATA-LRS. The addition of the Diver has effectively transformed a non-surgical robot arm into a system able to perform tasks similar as in robot assisted laparoscopy. The features of the SATA-LRS around cleanability and modularity are expected to benefit such systems, as well as its ability to change end-effector without disassembly.

AMAZING TECHNOLOGIES

P301—The first experience of using augmented reality technology in operations on the liver and pancreas

Dmitry Panchenkov ¹ , Z.A. Abdulkerimov¹, Yu.V. Ivanov², I.V. Semeniakin³, A.F. Gabdullin³, K.A. Tupikin¹, D.A. Astakhov¹, R.V. Liskevich¹

¹A.I. Evdokimov Moscow State University of Medicine and Dentistry, Surgery and Surgical Technologies, Russia, ²A.I. Evdokimov Moscow State University of Medicine and Dentistry, Minimally Invasive Surgery, Russia, ³A.I. Evdokimov Moscow State University of Medicine and Dentistry, Urology, Russia

Typically, surgeons study computed tomography (CT) and magnetic resonance imaging (MRI) data before surgery. This allowes to evaluate defferent variants of the blood vessels architecture and other anatomical features of the location of organs in each specific case. Planning the operation allows to reduce the risk of intra- and postoperative complications. However, there are a number of studies that show the limited ability of the surgeon to obtain an accurate understanding of the anatomical relationships of organs in the analysis of 2D images. The problem of effective interpretation of anatomy exists both in abdominal surgery and in urology when performing kidney resections of varying complexity. In order to improve the quality of interpretation of 2D images and a more accurate assessment of the scope and features of the planned operation, it was proposed to use 3D printing based on CT and MRI data. However, the application of this technology is time consuming, significantly increases financial costs and has limited availability. With the development of computer technologies and visualization methods, the idea of using the so-called augmented reality (AR) appeared in the planning of surgical interventions, as well as for the intraoperative orientation of the surgeon. Augmented reality makes it possible to create a high-quality virtual 3D model of the anatomy of a particular patient. The surgeon has the ability to view and control the AR model using a head-mounted display. It should be noted that the CT data used to create the AR models included 3D visualization of the rotation of the kidneys and the abdominal vasculature. These 3D images can be rotated horizontally, but they cannot be reconstructed and manipulated like AR models, which is also an advantage of using the technology. The use of AR models in urology has improved surgeons' understanding of the kidney anatomy of a particular patient and contributed to changing the original kidney resection plan in some cases. In abdominal surgery, the use of AR also takes place. Publications on this theme have been found since 2017 and belong to a group of authors from Germany and the USA.

The purpose of the study was to evaluate the possibilities of using augmented reality technology in operations on the abdominal organs.

Methods: The CT data obtained during the examination of the patient before surgery were processed in a computer program in order to obtain polysegmental models. The data obtained after processing were used in the HLOIA© software to create a virtual volumetric model of the organ, taking into account the anatomical features of a particular patient.

Prior to the operation and intraoperatively, second-generation Hololens virtual reality glasses from Microsoft (Seattle, Washington, USA) with the HLOIA© system implemented in them were used. From December 2021 to January 2022, three surgical interventions were performed using AR technology. The scope of operations was laparoscopic echinococcectomy with resection of the 5th and 6th liver segments for residual echinococcosis; laparoscopic pancreatoduodenal resection for pancreatic cancer and laparoscopic cystectomy of the mesentery of the small intestine.

Results: The use of AR technology did not significantly affect the planning of the scope of the operation, and also did not significantly influenced the time of the operations performed. At the same time, the use of AR facilitated the surgeon's orientation during liver resection and manipulation near the vascular-secretory elements for residual liver echinococcosis. When performing laparoscopic pancreatoduodenal resection, the use of AR contributed to a better understanding of the anatomy when creating a tunnel while the departing from the superior mesenteric and splenic veins, as well as determining the level of intersection of the pancreatic parenchyma. When removing a cystic tumor of the mesentery of the small intestine, the use of AR did not provide tangible advantages over the standard preoperative examination and planning of the scope of the operation. Nonetheless, after viewing the AR model, the surgeon became more confident in the anatomy of the vessels and the relationship of the removed tumor (or hydatid cyst) with vascular structures.

Conclusion: Preoperative and intraoperative viewing of interactive augmented reality models can increase the surgeon's confidence and improve understanding of the anatomy, especially in complex cases and when planning non-standard surgical interventions, optimize the operative approach, and in some cases change the initial operation plan. At the same time, further research is required to clarify the areas of application of augmented reality models and the possible development of a protocol for their use in abdominal and, in particular, hepatopancreatobiliary surgery.

AMAZING TECHNOLOGIES

P302—On the efficacy of high-resolution preoperative 3d reconstructions for lesion localization in oncological colorectal surgery—first pilot study

Domenico Soriero, S. Scabini, D. Pertile, A. Massobrio

¹Ospedale Policlinico San Martino, Chirurgia generale ad Indirizzo Oncologico, Italy

When planning an operation, surgeons usually rely on traditional 2D imaging. Colon neoplastic lesions are not always easy to locate macroscopically during surgery. The 3D virtual model may allow the surgeon to better visualize the anatomy. In this study we analyze and discuss the clinical impact of using such 3d models in colorectal surgery. This is a monocentric prospective observational pilot study including 14 consecutive patients who presented colorectal lesions with surgical indication. A staging CT/MRI scan and a colonoscopy were performed on each patient. CT scans and endoscopic informations were provided to obtain a 3D rendering (Fig. 1). The 2D images were shown to the surgeon performing the operation, while the 3D reconstruction to a second surgeon. Both of them had to locate the lesion and in the study the answers we compared. Lesions’ localization based on the 3D models and the histopathological findings had a 100% concordance, in contrast to conventional 2D CT scans which cannot detect the lesion in two patients. The 3D model reconstruction allowed an excellent concordance correlation between the estimated and the real lesion locations, allowing the surgeon to correctly plan the procedure with excellent Results: In addition, the use of the 3D models and of the preoperative plans during the actual surgical procedures shall be investigated, as this information has the potential to enable intuitive intraoperative guidance (e.g. based on AR/VR technologies). These findings shall be validated by a larger clinical study in the future.

AMAZING TECHNOLOGIES

P303—The influence of simulating cyclic diaphragm movement training on acquisition of basic laparoscopic skills with an actuated training platform

Jan-Willem Klok ¹ , R. Postema², J. Dankelman¹, T. Horeman¹

¹Delft University of Technology, BioMechanical Engineering, The Netherlands, ²Spijkenisse Medisch Centrum, Surgery, The Netherlands

Aims. Laparoscopic surgery has many advantages but comes with its own challenges. For example, the working space and field of view of the abdominal cavity is limited and often obstructed by organs. The abdominal cavity is flexible, dynamic and interactive with the rest of the patient’s body, causing the manipulated tissue to move. A contributor to abdominal tissue movement is respiration, transferred by the diaphragm. These are not introduced during basic laparoscopic skills training. The acquisition of sensory and motoric skills is crucial for safe surgery. Currently, little is known about the influence of simulated movement on training. Therefore, it was investigated if basic laparoscopic skills training with task movement has an influence on the acquisition of laparoscopic skills.

Methods. An actuated platform (DyLaP), compatible with a ForceSense laparoscopic box trainer was designed (Fig. 1), capable of simulating diaphragm movements. The movement fidelity was approved by a laparoscopic surgeon, characterized by an asymmetric sinusoidal with an amplitude of 12 mm, simulating 1.5 s of inhalation and 3 s of exhalation. During a pilot study, eight students divided into two groups were asked to perform a precision peg transfer task on a box trainer. One group performed six trails of the task without movement followed by an exam trail with movements (static group). The other group performed six trails with movement followed by an exam trail with movements (dynamic group). During all trails, time to task completion and forces in three directions exerted on the DyLaP were measured.

Results: Time to completion for the dynamic group exam was significantly lower than the static group exam (mean t = 208 s SD40s versus mean t = 142 s SD26s, respectively with p =  < 0.05). The time to completion learning curve (Fig. 2) showed that the dynamic group performed worse in the first trail compared to the static group. After the first trail, performance of both groups converged, with the exception of the exams. There was no significant difference in the forces exerted on the platform.

Conclusions: The DyLaP proved to be a useful tool to investigate the role of simulated organ movement in basic laparoscopic skills training. The pilot study showed that introducing simulated movement during laparoscopic training does have an influence on skill acquisition. It was observed that participants used stationary moments of the cyclic motion as windows of opportunity to place the rings. Regarding position-based tasks, predictable organ movement might be less relevant for skills acquisition. Therefore, it will be investigated if there is a relevant skill acquisition difference with a force-based task that requires full time contact. Also, training with disturbances of the diaphragm would be clinically relevant. Further research is needed to investigate whether force-based tasks and sudden movements have a relevant influence on laparoscopic skills training.

AMAZING TECHNOLOGIES

P304—A Retrospective Analysis based on Multiple Machine Learning Models to Predict Lymph Node Metastasis in Early Gastric Cancer (EGC)

Tao Yang ¹ , J. Martinez-Useros², I. Alarcón³, C. Li⁴, W.Y. Li⁵, Y.X. Xiao¹, X. Ji¹, Y.D. Zhao⁶, S. Morales Conde³, Z.L. Yang¹

¹The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou city, China, Gastrointestinal Surgery, China, ²Translational Oncology Division, OncoHealth Institute, Health Research Institute—Fundacion Jimenez Diaz, Avenida Reyes Catolic, OncoHealth Institute, Spain, ³University Hospital "Virgen del Rocio", Sevilla, Spain, Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, Spain, ⁴Autonomous University of Madrid, Madrid, Spain, Faculty of Medicine, Spain, ⁵The Sixth Affiliated Hospital of Sun Yat-sen University Guangzhou China, Oncology Center, China, ⁶The Sixth Affiliated Hospital of Sun Yat-sen University Guangzhou China, Department of Pathology, China

Background: Endoscopic submucosal dissection has become the primary option of treatment for early gastric cancer (EGC). However, lymph node metastasis may lead the prognosis. We analyzed factors related to lymph node metastasis in this group of patients and we developed a construction prediction model with machine learning using data from a retrospective series.

Methods: Two independent cohorts series were evaluated including 305 patients with EGC from China as training set, and 35 patients from Spain as a validation set. Five classifiers obtained from machine learning were selected to establish a robust prediction model for lymph node metastasis in EGC.

Results: The clinical variables such as invasion depth, histologic type, ulceration, tumor location, tumor size, Lauren classification, and age were selected to establish the five prediction models. Linear Support Vector Classifier (Linear SVC), Logistic regression model, Extreme Gradient Boosting model (XGBoost), Light gradient boosting machine model (LightGBM), and Gaussian Process Classification model. Interestingly, all prediction models of training set showed an accuracy between 70 and 81%. Furthermore, the prediction models of the validation cohort exhibited an accuracy between 48 and 82%. The Areas Under Curve (AUC) of the five models between the training and validation group were between 0.736 and 0.830.

Conclusions: Our results support that machine learning methods could be used to predict lymph node metastasis in early gastric cancer and improve patient management accordingly.

AMAZING TECHNOLOGIES

P305—Advancement in Technology and its Benefits in Gastrointestinal Stromal Tumours Resections

Madhu Chaudhury, C. Ball, V. Shetty, J. Ward, P.D. Turner, K.G. Pursnani

¹Royal Preston Hospital, Lancashire Teaching Hospital Trust, Upper GI Services, General Surgery, United Kingdom

Aim: In 2017, two of our Upper Gastrointestinal (GI) surgeons in our centre performed the first robotic Gastrointestinal Stromal Tumours (GIST) excision in the United Kingdom successfully. The patient was discharged 5 days later after an uneventful recovery. Our site has been involved in removing GISTs for over 10 years. With the surgical advancements, our techniques have upgraded from open to laparoscopic to robotic.

GISTs can arise in inconvenient locations (cardia, pylorus) and in different sizes. With the development of robotic surgery, the DaVinci robot has allowed the surgeon to perform precise wedge resection with high definition 3D visualisation and instruments with endowrist technology. This is all completed with the comfort and protection of the surgeon’s musculoskeletal system. This study was to see the changes in Length of Stay (LoS) with the advancement of technology.

Methods: Data of the cases were collected retrospectively from 2011–2021. The database comprised of open, laparoscopic and robotic cases amongst 5 surgeons. Cases where notes were unavailable were removed from data collection. Length of Stay (LoS) was statistically assessed using Mann–Whitney U test on SPSS v22.

Results: From 2011- 2021, we have completed 88 GIST resection cases. 19 (22%) cases were open, 61(69%) cases were laparoscopic and 8 (9%) cases were robotic. The median age of the patients were 59 years (ranging 48–82 years). The median length of stay for Open was 9 days (5–19 days), for laparoscopic it was 7 days (5–12 days) and for robotic 5 days (2–9 days). Our data suggested significant results comparing LoS between the 3 groups. Tumour negative margins were noted in all cases reviewed. Complementary table attached to show p-values.

Conclusion: Our current data trends show that as technology advances, there is a significant reduction in the total LoS in both ITU and the complete hospital admission. In addition, our robotic surgery data suggests increased success in removal of GIST tumours from challenging anatomical locations. This effectively reduces the requirement of formal major resection and reconstruction and ops for a wedge resection which subsequently reduces the need for HDU admission and improves functional outcome.

VIDEO PRESENTATIONS: UPPER GI—Gastroduodenal diseases

V001—The Wrong Diagnosis: this is not a Acute Cholecystitis

Rui Costa, A. Pereira, L. Graça, E. Barbosa

¹Centro Hospitalar Universitário de São João—Porto, Serviço de Cirurgia Geral, Portugal

Aims: Laparoscopic surgery is the best approach to acute abdomen since it can provide inspection to the entire abdominal cavity. This video aims to present a case of Perforated Peptic ulcer.

Methods: A 65 years-old woman presented at Emergency Department complaining of severe pain in Right Upper Abdominal Quadrant. A Abdominal ultrasound and blood tests were performed and the diagnosis of Acute Cholecystitis was made. A Laparoscopic Cholecystectomy was proposed.

Results: When laparoscopy was started, no signs of gallbladder inflammation were presented and biliary peritonitis was presented due to a perforated Peptic Ulcer.

A laparoscopic suture was made. The post operative period was uneventful.

Conclusion: Laparoscopic approach to abdominal emergencies should always be presented as it can provide the right treatment in an unexpected situation.

SOLID ORGANS—Adrenal

V002—Laparoscopic interaortocaval lymphadenectomy with indocyanine green (ICG) fluorescent-guided surgery for suspect recurrence of adrenocortical carcinoma

Vera D'Abrosca, E. Cassinotti, L. Baldari, V. Messina, F. Centonze, C.A. Manzo, L. Boni

¹Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico—Milan, General Surgery, Italy

Aim: This video shows our technique to perform laparoscopic interaortocaval and hepatic hilum lymphadenectomy for recurrent adrenocortical carcinoma with indocyanine green (ICG) fluorescent guided surgery for lymphnode mapping.

Methods: The patient is a 63-years-old woman who underwent laparoscopic right adrenalectomy for adrenocortical carcinoma (oncocytic variant) treated with adjuvant therapy with mitotane. One year after first surgery patient underwent follow-up fluorodehoxyglucose-positron emission tomography (FDG-PET) that showed two high hypercaptant lymphnodes localized in the interportocaval and interaortocaval space and an increased FDG uptake of the right adrenal loggia. Moreover a high serum cortisol and dehydroepiandrosterone levels were found. In the suspect of a recurrence the patient was scheduled for laparoscopic interaortocaval lymphadenectomy and resection of the right adrenal loggia residual fat. Fifteen minutes prior to surgery 5 ml of a diluition of 1.25 mg/ml of ICG were injected into the right inguinal lymphnodes with percutaneous ultrasound guided technique. Patient was placed left lateral position, four trocars were placed: 11 mm in subcostal right position, 12 mm in right flank and two 5 mm respectively under the xiphoid process and on the right anterior axillary line. Explorative laparoscopy with 4 K technology combined with NIR/ICG fluorescence vision was performed. Fluorescent lymphatic mapping from right inguinal region allowed to identify and precisely dissect the interaortocaval lypmhnodes. Procedure carried on with interaortocaval lymphonodal chain, portocaval lymphatic tissue and hepatic hilum lymphnodes dissection under ICG fluorescence guidance, alongside with the Gerota’s fat of the superior pole of the right kidney.

Results: The postoperative course was uneventful and the patient was discharged on postoperative day 4. Histopathological examination of the Gerota’s fat and the lymphatic tissue showed no adrenocortical carcinoma recurrence.

Conclusion: ICG fluorescence for lymphnode mapping is feasible and very helpful to perform a safe and thorough dissection of lymphatic tissue, especially in anatomical challenging sites such as the one illustrated in this case.

HERNIA-ADHESIONS—Emergency surgery

V003—Diaphragmatic Hernia: Abdomen in Thoracic Domain

A. Bhandarwar¹, Girish Bakhshi ¹ , A. Rachapalli¹, R. Gajbhiye², A. Wagh¹, S. Jadhav¹, A. Tandur¹, S. Bhondve¹, N. Dhimole¹, G. Bharadwaj¹, B. Ganesan¹, R. Bhat¹, A. Dutt¹, H. Padekar¹, E. Arora¹

¹Grant Government Medical College and Sir JJ Group of Hospitals, General Surgery, India, ²Government Medical College, Nagpur, General Surgery, India

Aims: Adult Diaphragmatic Hernias remain a rarity. Only 0.17—6% diaphragmatic hernias are discovered in adulthood. There are only 20 right sided adult cases reported in literature. The purpose of this video is to present a composite Thoraco-Laparoscopic approach in the management of adult diaphragmatic hernia in both emergency and elective settings, practiced in our hospital.

Methods: We present an ongoing case series of the past 5 years, at Sir JJ Group of Hospitals, Mumbai, encompassing 17 patients with CT proven Diaphragmatic Hernias. Post reduction, the diaphragmatic defects were closed primarily with sutures and composite mesh placements were performed for defect sizes more than 3 cm. All patients were operated via a composite Thoraco-Laparoscopic approach. The contents of the hernia were reduced laparoscopically and the defect was closed and reinforced with a composite mesh, thoracoscopically. Patients were followed up with regular clinico-radiological checkups.

Results: A total of 17 patients were included in this study, one of whom presented with a right sided diaphragmatic hernia. The average defect size was 4 cm. The mean operative time was 150 min. Patients had a mean hospital stay of 6 days with atelectasis as the most common complication. There were no recurrences noted at the 6 months follow up.

Conclusion: Diaphragmatic hernia can be a life threatening condition. Owing to the high risk of strangulation and intestinal obstruction, all cases of diaphragmatic hernia should be diagnosed early and operated immediately. Use of dual mesh is a good option for repair of diaphragmatic hernia with defect size more than 3 cm. Emergency/elective endoscopic approach is a safe and feasible option in young and optimized patients. A composite Thoraco-Abdominal approach improves the ergonomics to accomplish the procedure.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V004—Laparoscopic Whipple pancreatoduodenectomy—replaced hepatic artery from superior mesenteric artery (type 5)

Michał Pędziwiatr, M. Wierdak, A. Zub-Pokrowiecka, J. Rymarowicz

¹Jagiellonian University Hospital, 2nd Department of General Surgery, Poland

Arterial variants are relatively common in pancreatic head surgery. Therefore, one has to be careful during dissection in order to correctly recognise and prevent damaging these anatomical structures. We present a rare case of a 57-year-old female (BMI 22.4 kg/m2) patient with main duct IMPN with high-grade dysplasia in the head of the pancreas. In preoperative imaging an unusual anatomical variant has been found—fully replaced hepatic artery originating from superior mesenteric artery (type 5). This condition is found in less than 2.5% cases. In this video we focus on the technique of arterial identification and show how to safely dissect the artery from the pancreatic head. Although laparoscopic approach is demanding we find it feasible and safe for the patient with this anatomical anomaly.

UPPER GI—Benign Esophageal disorders

V006—Solitary fibrous tumor of the esophagus: pure thoracoscopic approach

Alfonso Lapergola ¹ , B. Dallemagne², A. D'Urso¹, A. Olland³, D. Mutter¹, S. Perretta¹

¹Nouvel Hopital Civil, University of Strasbourg, France, Visceral and Digestive Department, France. ²IRCAD Strasbourg/University of Strasbourg, Visceral and Digestive Surgery, France, ³Nouvel Hôpital Civil, University of Strasbourg, Thoracic Surgery and Transplant Department, France

Aims: Solitary fibrous tumors (SFTs) are soft tissue neoplasms of pluripotent fibro/myofibroblastic origin microscopically consisting of reticulin and collagen whorls with interspersed spindle cells. They present unique immunohistochemistry characteristics, distinguishing them from other similar and more common spindle cells or mesenchymal tumors. They typically arise from the pleura or meninges, but can originate from anywhere in the body and can present malignant behavior. Only 7 cases of esophageal SFTs have been reported in the English literature to date. The aim of this video is to present a full thoracoscopic resection technique of this rare lesion.

Methods: A 74-years-old man presented to our unit with history of progressive dysphagia associated with weight loss and other occasional symptoms, like odynophagia and hiccups. Endoscopy with EUS and contrast-enhanced-CT documented the presence of an extra-digestive, “cystic” lesion located in the inferior third of the esophagus responsible for an extrinsic obstruction of the lumen. A fibro-bronchoscopy excluded airway compression and a bronchial origin of the cyst. The patient was scheduled for surgery with hypothetical pre-operative diagnosis of esophageal duplication cyst.

A right thoracoscopic approach with a prone-positioned patient was chosen. Four trocars were used: a 12-mm camera trocar, two working trocars (5 and 12-mm) and a 5-mm assistant trocar. Exploration of the right thoracic cavity showed dilatation of the esophagus in correspondence with the underlying tumor. After dissection and preservation of the vagus nerve, a longitudinal incision of the esophageal muscular layers was made to expose the submucosa, from which an encapsulated whitish mass was gently separated using blunt dissection until reaching its base of implantation, which was finally resected using a vascular linear stapler. The esophageal muscle wall was then closed over the submucosa with a running suture. A chest drain was left in place and removed on postoperative day 2.

Results: The operating time was 95 min with no blood loss. After an uneventful postoperative course, with a normal upper GI series on the first postoperative day, the patient was discharged on the fourth day. Histologically, the 14.5 × 3.5x2 cm encapsulated mass showed a patternless proliferation of spindle cells without atypia or necrosis was detected. The surgical margins were free of disease (R0). Immunohistochemically, these cells showed positivity for CD34 and STAT-6, but were α-SMA-, CD-117-, S-100- and Dog-1-negative. The Ki67 proliferation index was estimated at 5%. The diagnosis of benign SFT of the esophagus was made. At 24 months, the patient is totally asymptomatic and has recovered his normal weight without sign of tumor recurrence.

Conclusions: Esophageal SFT are extremely rare entities, whose diagnostic workup and treatment management can be challenging for the surgeon. Conservative thoracoscopic resection is safe and feasible in experienced hands, representing a good surgical option for the treatment of this rare lesion.

ROBOTICS & NEW TECHNIQUES—Bariatrics

V007—Robotic SASI—Single Anastomosis Sleeve Ileal Bypass as a First or Second Stage Bariatric Treatment for Obesity: Report of First Series

Ricardo Zorron, W. Eskander, M. Specht, C. Grande

¹Klinikum Ernst von Bergmann Potsdam, Center for Bariatric and Metabolic Surgery, Germany

Background: For superobesity, first-line bariatric surgeries like Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB) might lead to unsatisfactory results: Meanwhile, the risk of weight regain after SG was 19.2%–75.6% and superobesity trend to regained weight more rapidly after surgery.

Objectives: A novel bariatric procedure- single anastomosis sleeve ileal (SASI) bypass was reported to be a safe, feasible and effective treatment for obese patients, while with low postoperative morbidity and mortality. The SASI bypass for superobesity performed with robotic system DaVinci has not yet been described.

Methods: This is a case study of robotic single anastomosis sleeve ileal (R-SASI) bypass, which was performed as a second stage bariatric treatment for a 30-y-old superobese patient. The R-SASI bypass was consisted with 6 steps, including step 1. Set up robotic operation platform, step 2. Sleeve stomach is dissected, step 3. Identifying ileocecal junction, step 4. 300 cm ileum measured upwards, step 5. Gastroileal anastomosis is created, and step 6. Jejunoileal anastomosis is created. Finally, sleeve stomach had two outlets, one to the duodenum and another to the ileum, while jejunoileostomy could help to avoid the bile reflux in the stomach.

Results: The perioperative outcomes of the superobese patient were uneventful. The postoperative stay was 2 days. Follow up at 30 days showed 9 kg weight loss.

Conclusions: SASI bypass is potentially safe option as the second stage bariatric treatment for superobese patient after sleeve gastrectomy. The long-term follow-up results is subsequently required to evaluate the efficacy of SASI and Robotic-SASI bypass.

HERNIA-ADHESIONS—Abdominal wall hernia

V008—Transversus Abdominis Muscle Release (TAR) via ETEP (ETEP-TAR) for complex Ventral Hernia: step-by-step

Jeancarlos Trujillo Diaz, P. Concejo Cutoli, J.R. Gómez López, C. Martinez Moreno, J. Atienza Herrero, J.C. Martin del Olmo

¹Medina del Campo Hospital, Valladolid, General and Digestive Surgery Department, Spain

Aims: Ventral hernias are a common pathology in general surgery. Its treatment by laparoscopic approach is increasingly frequent. In large complex hernias the preoperative application of botulinum toxin (BT) and progressive pneumoperitoneum are very useful. The surgical technique for the repair of this type of hernias is ideally a retromuscular technique associated or not with a posterior separation of components (transversus abdominis muscle release—TAR). The retromuscular-preperitoneal approach is a technique that is being performed more frequently due to the more anatomical position of the mesh, the lower rates of complications and recurrences in the short and long term. In addition, lately its performance has been increasing using minimally invasive techniques, further improving the results already described. We present the detailed step-by-step eTEP-TAR surgical technique.

Methods: Video-case presentation.

Results: 75-year-old man with surgical histories: lap-cholecystectomy and abdominal aortic aneurysm 7 years ago. Physical examination: midline complex ventral hernia (M2-3-4W3:10 cm). CT scan: midline ventral hernia with small bowel and colon into the hernial sac. 4 weeks before surgery we injected BT according Ibarra-Hurtado technique. We decided to perform a laparoscopic approach (eTEP).

We use 5 ports to perform the surgery. The surgery begins dissecting the right retromuscular space. We cross-section the right posterior sheath and enter the abdominal cavity and release all the small bowel adhesions. We then proceed to open the left posterior sheath and dissect the retromuscular space. The dissection continues down to the pubis. We observed tension to close the posterior sheath so we decided to perform a bilateral-TAR. We begin the right-TAR down-to-up and after that the left-TAR up-to-down using the monopolar cautery and the Ligasure. We continue with the closure of the posterior and the anterior sheaths using 2–0 V-lock suture. We place a 30 × 25 cm PVDF mesh fixed with glue and leave a drainage.

The patient presented a satisfactory evolution without complications and was discharged in 2ºPOD.

Conclusions: The association between preoperative botulinum toxin and enhanced view totally-extraperitoneal approach (eTEP) is a valid, effective and safe option in cases of complex ventral hernia, such as the one presented. Posterior component separation techniques (TAR) allow us to achieve a correct and tension-free closure of the abdominal wall.

HERNIA-ADHESIONS—Abdominal wall hernia

V009—Extended View Totally Extra-Peritoneal (eTEP) Approached Retromuscular Repair as a Treatment of Ventral Hernias with Rectus Diastasis—Surgical Technique

H. Maes¹, Sam Kinet ¹, S. Kinet², E.F.P. Kuppens², S. Van Cleven²

¹AZ Alma, Surgery, Belgium, ²AZ Alma Eeklo, Surgery, Belgium

Objective: To assess the feasibility of a minimally invasive extended view totally extraperitoneal (eTEP) approach in the treatment of rectus abdominis diastasis with ventral hernias. To provide a detailed explanation of the procedure in the form of a descriptive intra-operative video with captations.

Methods: We aim for the use of three balloon inflated trocars in total, all along the semilunar line, the first one is inserted with an open technique in the right upper quadrant. Then we start with ipsilateral retrorectus dissection by endoscope. Following steps are ipsilateral medial posterior rectus sheath (PRS) opening, preperitoneal dissection, contralateral medial PRS opening, contralateral retrorectus dissection, bilateral PRS release with continuation of preperitoneal and retrorectus dissection, PRS release around hernia sac, and reduction of the hernia sac respectively. Next we measure the ventral hernia and rectus abdominis diastasis. We then reeve the midline and reapproximate the rectus abdominis muscles. Finally we position a retromuscular mesh, which we often fixate with cyanoacrylate glue depending on surgeon preference.

Results: From September 2021 through June 2022, we treated a total of 35 patients with this eTEP technique. Except for three patients without rectus diastasis and one patient without a ventral hernia, all other patients presented with ventral hernias alongside rectus diastasis. We did not encounter any recurrences to date. Conversion to open repair was needed in four patients.

Conclusion: In our experience, the minimally invasive eTEP approach is feasible when compared to open repair in the treatment of ventral hernias with rectus abdominis diastasis. Skin-to-skin time ranged from 251 to 119 min, not including the conversions. The number of trocars used declined from six to three. Hospitalization ranged from 2 to 8 days with a mean of 3.457 (± 1.421) days.

HERNIA-ADHESIONS—Emergency surgery

V010—Use of indocyanine fluorescence in abdominal hernias with bowel incarceration—initial case series

Clarisa Birlog, G. Filip, V. Tomulescu, L. Bărbulescu, E. Cătănescu, S. Filip, O. Arnăutu, F. Turcu, C. Copăescu

¹Ponderas Academic Hospital, General Surgery, Romania

Background: Bowel incarceration represents an appalling complication for patients with abdominal wall hernias. Evaluating the bowel perfusion after the eventual hernia reduction can be challenging, especially in emergency conditions. We discuss here the first series of incarcerated hernias in patients presenting at the emergency room with suspicion of strangulation for whom we used intraoperative indocyanine green (ICG) angiography to assess bowel perfusion to improve the fundaments of the decision to preserve the affected segment.

Material and methods: Twenty-four consecutive patients undergoing emergency laparoscopic exploration for incarcerated umbilical or inguinal hernia with suspicion of strangulation (irreducible hernia, recent onset of pain, ultrasound and/or tomographic criteria for ischemia) were included in this retrospective study, from January 2019 to November 2021. Data regarding imaging characterisation of the suffering intestinal loop, enteral and omentum resections, reinterventions, and postoperative course were collected and analyzed.

Results: Of the 24 patients who underwent exploration laparoscopy and ICG bowel perfusion assessment, eight had the hernia sac reduced with bimanual maneuvers (intraperitoneal traction with a grasper and gentle extracorporeal reduction) without adhesiolysis. The other sixteen patients required blunt and scissors adhesiolysis (66%). All of them were administered intravenous ICG, and in 4 cases, resection of the intestinal loop was performed. In one case, omentectomy was decided after photodynamic eye evaluation with no visible perfusion. No reinterventions were required, and the postoperative course in all the patients was uneventful.

Conclusions: Intraoperative ICG fluorescence angiography is a valuable method for bowel perfusion evaluation, and it should be a first-to-go-to tool for assessing intestinal ischemic status in patients with incarcerated hernias.

HERNIA-ADHESIONS—Inguinal hernia

V011—Laparoscopic approach to Hydrocele of Canal of Nuck: A retrospective review of six cases

A. Bhandarwar¹, Supriya Bhondve ¹ , G. Bakhshi¹, R. Gajbhiye², A. Wagh¹, S. Jadhav¹, E. Arora¹, A. Tandur¹, N. Dhimole¹, K. Reddy¹, G. Bharadwaj¹, H. Padekar¹, A. Dutt¹, R. Bhat¹, B. Ganesan¹

¹Grant Government Medical College and Sir JJ Group of Hospitals, General Surgery, India, ²GMC Nagpur, General Surgery, India

Introduction: Extremely rare pathology, Canal of Nuck hydrocele, occurs in less than 1 per 1 lac persons worldwide, with preponderance in children. Initially thought to be due to a patent processus vaginalis, alternate theories propose remnants of mesenchymal cysts as the root cause. They are usually misdiagnosed as inguinal hernias and are detected accidentally during groin exploration. Of interest, a right-sided preponderance has been observed without any plausible explanation given in literature.

Methods: This study is a retrospective review of a database of 6 female patients who presented with similar inguinal swellings and were diagnosed as mesothelial cysts of round ligament of uterus by one of the myriad radiological modalities (USG/CT/MRI) or by post-operative histopathological examination. The presenting symptom in all cases was inguinal swelling. Imaging techniques are an essential aid, as clinically it becomes very challenging to diagnose this condition with great certainty. Patients were operated laparoscopically via Trans Abdominal Pre-Peritoneal approach with placement of mesh.

Results: Amongst 6 patients with Hydrocele of canal of Nuck, 4 patients had right side swelling, 1 with left side and 1 patient had bilateral swelling. The presenting symptom in all cases was inguinal swelling.Short post-operative stay (max 5 days) and minimalistic complications (Seroma in 1 patient) were witnessed in our series.

Conclusion: Series emphasises the ease of laparoscopic approach and importance of excision of round ligament regardless of the approach. Although rare, hydrocoele of canal of Nuck should be included in the differential diagnosis of a groin lump in females.

HERNIA-ADHESIONS—Abdominal wall hernia

V012—Laparoscopic TAPP repair of left sided primary lumbar hernia- a case report

N. Kirmani, Lamis Abdelkarim

¹Princess Alexandra Hospital, General Surgery, United Kingdom

This is case report of a 44-year-old fit and well male referred by GP to outpatient general surgery clinic with complains of intermittent pain and lump in the left lumbar region for over 2 years. The lump was interfering with his work and day to day activities. On examination he had a lump in left lumbar region with a cough impulse present.

He had USS and CTAP which confirmed the finding of a left superior triangle lumbar hernia.

Patient underwent a trans-abdominal pre-peritoneal laparoscopic repair of primary lumbar hernia with insertion of a prosthetic mesh. There were no intra-operative complications and the patient was discharged home the same day.

Primary lumbar hernias are rare and can arise through posterolateral abdominal wall defects. Approximately three hundred cases have been reported in the literature since 1672 out of which only 20% are congenital and 80% are acquired. The acquired lumbar hernia are further classified into spontaneous (primary) or secondary.

The laparoscopic repair of lumbar hernias is safe and effective with good post-operative recovery.

HERNIA-ADHESIONS—Abdominal wall hernia

V013—How do I manage an Intraoperative Bleeding after a Sugarbaker reparation for an Incisional Hernia ??

M. Milagros Delgado Morales¹, Eugenio Licardie Bolaños ¹ , A. Ramírez Redondo¹, R. Santos Rancaño², J.F. Guadalajara Jurado¹

¹Hospital Infanta Elena, General Surgery, Spain, ²Hospital Comarcal de Melilla, General Surgery, Spain

Aims. The parastomal hernia represents a controversial item in the wall surgery field, due to the frequency of occurrence in ostomized patients, as well as the different surgical techniques (open and laparoscopic) that exist. Sugarbaker Technique constitutes the gold standard technique for the reparation of this type of hernia.

We present the case of a 66-year-old man who was diagnosed with a lower rectum adenocarcinoma in 2019, and underwent an abdominoperineal amputation with posterior adyuvant therapy. He was referred to our service from the ostomy department with a parastomal hernia.

Methods: The CT scan confirmed a type III incisional hernia (EHS classification). We performed a laparoscopic approach to repair the wall defect.

Surgical technique: We found a 6 × 5 cm parastomal hernia. After pneumoperitoneum, we localized the wall defect and we performed reduction of the hernial content and section of adhesions. A 16 × 15 cm Dynamesh protesis was placed around the defect as the Sugarbaker Technique describes. The mesh was fixed with Tackers and Cianocrilate. When we were ending the intervention, an active bleeding was seen in the hernial wall defect, and we were not able to stop it with compression nor with the application of a thrombin-gelatin hemostatic matrix. We decided to open the mesh by cutting it in the middle, exploring the hernia cavity and verifying an active bleeding from an arterial vessel; which was controlled by electrocoagulation. Finally, a new Dynamesh protesis was placed on top of the previous one, also using the Sugarbaker Technique. We reviewed haemostasis and ended the intervention.

Results: The patient was discharged at the second day of the intervention without any complications more than the intraoperative bleeding. Follow-up at the first month, sixth months and one year after the intervention does not evidence any signs of recurrence.

Conclusions: We have not found any case in the literature of intraoperative bleeding using Sugarbaker technique prior to the ending of the intervention. We think that the described technique can be a useful way to solve this complication when it occurs.

BARIATRICS—Endoluminal

V014—Combined endoscopic and percutaneous rescue of fully disrupted gastro-jejunal anastomosis after laparoscopic gastric bypass

Alfonso Lapergola ¹ , M. Vannucci², A. Garcia³, D. Mutter¹, S. Perretta¹

¹Nouvel Hôpital Civil, Strasbourg, Visceral and Digestive Department, France, ²University of Turin, Surgery, Italy, ³Institute of Image-Guided Surgery, Institut Hospitalo-Universitaire (IHU), France

Aims. Laparoscopic gastric bypass (LGBP) complications rate can reach up to 17% and its perioperative and postoperative mortality rates are 0.38% and 0.72% respectively, with anastomotic leak being the most common cause. Complete dehiscence of the gastro-jejunal (GJ) anastomosis, although rare, is particularly challenging since surgical repair may not be immediately possible. Endoscopic and percutaneous treatments can be a bale out option as a bridge-to-surgery. The aim of this video is to show a combined endoscopic and percutaneous rescue management in a case of complete gastrojejunostomy disruption after LGBP.

Methods: A 41-year-old female (BMI 34) underwent LGBP in July 2021 in another center. She was referred to our unit after an emergency laparotomy was performed on postoperative day (POD)-22 for active bleeding and peritonitis due to full anastomotic dehiscence and gastric remnant staple line disruption. At that time, the proximal stapling was performed at the level of the esophagogastric-junction (EGJ) and partial gastric remnant resection was also performed. An abdominal drain was left in the left hypochondrium. Gastrostomy and jejunostomy were also performed.

On arrival to our center on POD-32 the CT scan showed a voluminous hydro-aerial collection occupying the left hypochondrium secondary to a dehiscence of the EGJ stapling line. An endoscopy allowed to confirm the dehiscence of the stapling at the EGJ and visualize the abdominal drain.

An endoluminal-vacuum system (Endo-Sponge) through aspirated nasogastric tube was initially used to control the fistula and changed a total of three times every 48 h for one week, but not tolerated by the patient. Decision was made to attempt a percutaneous rendezvous drainage inserting a 0.035-inch hydrophilic guidewire percutaneously under fluoroscopy through the corrugated abdominal drain. The guidewire was retrieved endoscopically and exteriorized though the mouth. Under endoscopic and fluoroscopic control, a T-tube was inserted transorally, advanced over the guidewire and exteriorized through the abdominal wall leaving the T-portion in the distal oesophagus.

Results: This manoeuvre allowed successful drainage of intra-abdominal collection and saliva with correction of the septic status, allowing a delayed surgical oeso-jejunal reconstruction.

Conclusion: Multimodal treatment combining endoscopic and percutaneous approaches can represent an effective option in the management of complicated dehiscence, fistulas or leaks after bariatric procedures even after failure of surgical rescue.

BARIATRICS—Laparoscopic

V016—Hiatal hernia repair in a patient with previous Roux-en-Y Gastric Bypass and obstructive symptoms

Pedro Soares-Moreira, F. Marrana, D. Melo Pinto, T. Moreira Marques, L. Barbosa, R. Peixoto, G. Faria

¹Unidade Local de Saúde de Matosinhos, General Surgery, Portugal

Aims: Description of a possible surgical definitive solution for symptomatic Hiatal Hernia (HH) after Roux-en-Y Gastric Bypass (RYGB).

Methods: Video presenting clinical case and surgical technique of a patient that developed GERD after RYGB.

Background: Gastric bypass is still considered the gold-standard of metabolic and bariatric surgery. It is a safe and effective treatment for morbid obesity and many of its associated comorbidities. Long-term complications though rare might include mechanical obstructions. Symptomatic obstruction caused by hiatal herniation is rare and few cases have been reported. The physiopathology of hiatal hernias after gastric bypass may result from several factors, including changes in tissue strength due to rapid weight loss and dissection injury of the diaphragm crura. However, due to the gastro-jejunal anastomosis, most hiatal hernias remain asymptomatic.

Results: We present the clinical case of a 59-year-old patient that reported dysphagia to solid food, epigastric pain and heartburn in the follow-up of laparoscopic RYGB. Abdominal CT revealed a sliding hiatal hernia with the gastric pouch and gastro-enteral anastomosis in the thoracic cavity. Surgical repair of this defect was accepted by the patient. This video reports the technique of a laparoscopic hiatal hernia repair. After complete dissection and mobilization of the gastric pouch and distal esophagus, we performed a cruroplasty reinforced with a bioabsorbable mesh. To prevent relapse and reflux, we carried out a fundoplication with the gastric remnant from the index surgery. There were no surgical or post-operative complications and the patient was discharged at post-operative day 2. At follow-up the patient.

reported improvement of heartburn, dysphagia and pain.

Conclusion(s): Although rare, symptomatic hiatal hernias following RYGB might need surgical treatment. Complete and careful dissection of the gastric pouch, anastomosis and distal esophagus is required and the use of the remnant fundus, might help in relieving symptomatic reflux.

BARIATRICS—Laparoscopic

V017—Laparoscopic Gastric Bypass Conversion to SADI-S with use of Indocyanine Green Fluoroscopy

Francesco Mongelli ¹ , F. Garofalo², A. Cristaudi², D. La Regina¹, M. Podetta³, M. Marengo⁴, S.G. Popeskou²

¹Ospedale Regionale di Bellinzona, Surgery, Switzerland, ²Ospedale Regionale di Lugano, Surgery, Switzerland, ³Hôpital d'Yverdon-les-Bains, Surgery, Switzerland, ⁴Ospedale di Locarno, Surgery, Switzerland

Introduction: Single Anastomosis Duodenal Ileostomy—Sleeve (SADI-S) is a relatively new bariatric procedure devised with the purpose of simplifying the complexity of the duodenal switch technique while maintaining its efficacy, especially in the cases of super obese patients and failure of primary bariatric procedures. Revisional surgery after Roux-en-Y gastric bypass (RYGB) is a challenging problem facing bariatric surgeons today. Conversion from RYGB to SADI-S might provide the most durable weight loss in comparison to other surgical procedures currently available. It can be performed either in one or two stage procedures laparoscopically.

Methods: A 60-year-old woman was referred to our bariatric surgery service 12 years after RYGB due to insufficient weight loss. The actual BMI was 48 kg/m2 and she suffered from sleep apnea under continuous positive airway pressure therapy (C-PAP) treatment, type 2 diabetes on oral medications and arterial hypertension. Preoperative investigations included gastroscopy, colonoscopy, barium study, CT abdomen, nutritional status and psychological evaluation. The preoperative work-up revealed a large pouch with a 3 cm diameter gastro-jejunostomy. Conversion to SADI-S was offered in two stages, the first being the conversion to sleeve gastrectomy.

Results: The patient was placed in a standard bariatric surgery position. Three 12 mm trocars and one 5 mm trocar were used for the laparoscopic procedure. After lysis of adhesions between the liver and the stomach, our first step was the resection of the gastro-jejunostomy with pouch resizing. Hand-sewn gastro-gastrostomy was created before performing the sleeve gastrectomy. Given the significant risk of gastric leak associated with this procedure, we used indocyanine green (ICG) perfusion test to verify adequate vascularization. The jejuno-jejunostomy was then resected and restoration of the intestinal continuity was achieved by creating a new anastomosis between the alimentary and the biliary limb stumps. The patient recovered well after the operation. She was discharged at day 3. At 4 months follow-up she has had a weight loss of 10 kg. We then proceeded to the second stage operation, a conversion to SADI-S. We have created a hand-sewn duodeno-ileal anastomosis between the first part of the duodenum and the ileum. We have used the ICG perfusion test to confirm a well vascularized anastomosis. The patient had no post-operative complications. She was discharged at day 2. At 6 months since the first operation, she had presented a weight loss of 20 kg.

Conclusion: Failure of RYGB is a challenging problem in bariatric surgery. A two-stage approach with first conversion to sleeve gastrectomy seems to be safe and feasible. The use of ICG test may be helpful in such complex reconstructions.

BARIATRICS—Laparoscopic

V018—Technical Details of Laparoscopic Conversion of the failed Roux-Y Gastric bypass into Duodenal Switch or Single Anastomosis Duodeno-Ileostomy + Sleeve Gastrectomy

Andrei Keidar, E. Carmeli

¹Assuta Ashdod Hospital, Surgery, Israel

Background: The Roux-en-Y gastric bypass (RYGB) is a very effective treatment for obesity and its related co-morbidities. However, some patients fail to achieve 50% of their excess weight loss (EWL), and others regain much of the weight that they lost.

Objective: The purpose of this video is to present technical details of conversion of RYGB to Duodenal Switch (DS)or Single Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADIS) in a single step.

Methods: This procedure may differ by: 1. Number of steps—one or two (conversion to a sleeve first, addition of Duodeno-Ileostomy as a second); 2.Techniques of the Gastrogastric anastomosis- hand-sawn, versus stapled; 3. Two anastomosis DS (RYDS) vs SADIS; 4. Resection or preservation of the Roux- limb, and more.

Results: We present a video that describes several different techniques of patients who underwent revision for failed RYGB into SADSIS or DS, discussing the differences, benefits and downsizes of both.

BARIATRICS—Laparoscopic

V019—Laparoscopic RYGB after open Nissen 30 years ago: challenge accepted.

Francisco Marrana, D. Melo Pinto, T. Moreira Marques, R. Peixoto, P. Soares Moreira, T. Rama, G. Faria

¹Unidade Local de Saúde de Matosinhos, General Surgery, Portugal

In the last decades, we’ve seen a rising of the prevalence of the obesity epidemic throughout the world. This epidemic has been associated with a proportional increase in obesity-related comorbidities, which include gastroesophageal reflux disease (GERD), among others.

Obese patients have three times more risk than the average patient to develop GERD and have more severe and frequent symptoms, because obesity is associated with several conditions predisposing to GERD, including esophageal motility disorders, higher incidence of hiatal hernia, diminution of lower esophageal sphincter pressure, and increase of intragastric pressure. In these patients, anti-reflux procedures such as Nissen fundoplication are reported to have a higher failure rate, with complications like a slipped, herniated or disrupted wrap.

In recent years, several studies reported that, despite increased technical difficulty, longer operative times and increased perioperative morbidity, Roux-en-Y gastric bypass (RYGB) after previous anti-reflux surgery such as laparoscopic Nissen fundoplication, presents as a feasible option, in the right hands, for obese patients with recurrent GERD, because it provides long-term symptom resolution and solid weight loss.

We present a case of a 64-year-old female patient with obesity (BMI 49 kg/m2) and recurrent GERD 30 years after an open Nissen fundoplication. This patient underwent an upper GI endoscopy that showed signs of chronic gastritis, without metaplasia or dysplasia. A laparoscopic conversion to RYGB was proposed. In the video of this surgery, marked by several technical difficulties between multiple adhesions and distorted anatomy in a patient with previous laparotomy, the fundoplication was taken-down and the RYGB was performed. The patient had an uneventful pos-operative period and was discharged after 3 days. Since this surgery she reports great improvement of GERD symptoms and has been losing weight as expected.

From this video presentation, we conclude that, although challenging and risky, the conversion from an open Nissen fundoplication to a RYGB still remains as the best option for the obese patients with recurrent GERD.

UPPER GI—Gastroduodenal diseases

V020—Laparoscopic Decompression of the Median Arquate Ligament

B. Martínez Mifsud, Paula Domínguez, D.M. Momblan, P. Domínguez, X. Morales, E. Butori, V.E. Gonzabay, A.M. de Lacy Fortuny

¹Hospital Clinic de Barcelona, General and Digestive Surgery, Spain

Aim: The Median Arcuate Ligament Syndrome (MALS) or Dunbar Syndrome, is a rare cause of chronic abdominal pain. Although pathophysiology is poorly understood, the compression of the celiac artery or the celiac plexus nerves caused by this fibrous band joining both diaphragmatic pillars, has been associated with, chronic abdominal pain, which is worsened with eating, or exercising as if it were an intestinal ischemia. Due its low incidence and variable severity of symptoms, MALS diagnosis is controversial, being the Angio-TC the gold standard. Respiratory techniques are used, since the lesion is predominantly visualized on expiration, however, in severe cases, it may appear as persistent compression on inspiration.

The present video aims to show an example of surgical decompression of the median arcuate ligament by laparoscopic approach, demonstrating its safety and feasibility.

Methods: 63-year-old, with a medical history of hiatal hernia; laparoscopic cholecystectomy, appendectomy and hysterectomy, consulted for diffuse abdominal discomfort and distension since she was 18 years old, associated with anorexia and weight loss. She reported occasional epigastric abdominal pain unrelated to ingestion. Due to long-standing abdominal pain, multiple diagnostic tests were performed with no pathological Results: Eventually, CT-angiography showed up an 80 stenosis of the proximal segment of the celiac trunk adjacent to the ostium in relation to the median arcuate ligament. An exploratory laparoscopy was performed, to release the Celiac Trunk. Firstly the left gastric artery was identified and referenced, subsequently the aorta and the fibers of the arcuate ligament were identified to be sectioned.

Results: The procedure lasted 36 min. The patient was discharged 24 h after the procedure, with a good response to oral reintroduction and control of postoperative pain.

Conclusions: MALS is a rare cause of chronic abdominal pain that must be considered specially in young women with anorexia and epigastric pain of years of evolution. Its low incidence can lead to a long diagnostic delay.

The surgical treatment that represents the minimally invasive surgery of laparoscopic release of the median arcuate ligament is technically feasible, safe and with good Results:

UPPER GI—Benign Esophageal disorders

V021—Robotic giant hiatal hernia repair—Our “step by step” surgical technique

Graziano Ceccarelli ¹ , M. Valeri², L. Trentavizi¹, F. Arteritano¹, M.T. Federici¹, G. Tacchi¹, F. Ermili¹, L. Mariani¹, W. Bugiantella¹, M. De Rosa¹

¹San Giovanni Battista Hospital, General Surgery, Italy, ²University of Perugia, General Surgery, Italy

Background: The intrathoracic migration of one-third or more of the stomach with or without other organs (colon, spleen, pancreas, etc.) is commonly defined as “giant” hiatal hernia. Minimally invasive repair is a safe and effective procedure, anyway it may be challenging, with an high rate of recurrence disease; so it requires advanced laparoscopic skills and learning curve in upper-GI functional surgery. Robotic approach may offer important advantages.

Methods and Results: A total of 31 giant hiatal hernias in a 15-yeras period, underwent robotic-assisted repair, at our general and minimally invasive surgical unit. The mean age was 67.7 yeras (47–88), 22 females and 9 males. 3 cases were treated in emergency setting. The conversion rate was of 1 case (3.2%). A post-operative follow up using barium swallow, as well as a Quality of Life questionnaire and endoscopy were performed at 6 and 12 months after surgery. Oesophageal manometry, and CT scan were performed only in selected cases. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge. Intraoperative complications were 3 pleural lesions and one gastric perforation, all these cases were treated intaroperatively. The Clavien-Dindo grade 3 in two cases: consisting in postoperative pnx requiring chest tube placement and one grade 4: reoperation for a non absorbable mesh migration into the stomach.

In the video shows the main steps of the technique. A standardization of the technique was performed in the last 22 cases. It consists in: preliminary abdominal exploration, reduction of the thorax content into the abdomen, the sac excision, the cruroplasty using pladgets reinforcment, a absorbable mesh placement (Bio-A), tailored fundoplication and gastropexy.

Conclusion: The robotic approach to giant hiatal hernia represent a good indication for the use of this technology, offering interesting advantages in better view, sac dissection, suturing step, compared to conventional laaproscopy. Respecting the main surgical steps we described the complication and recurrence rate in our experience was significantly reduced.

UPPER GI—Gastric cancer

V024—Laparoscopic treatment of a voluminous bleeding gastric GIST

M. Di Giuseppe¹, Daniele Provenzi ¹ , S. Spampatti², F. Iaquinandi², M. Marengo¹

¹Ente Ospedaliero Cantonale—Locarno, Surgery, Switzerland, ²Ente Ospedaliero Cantonale—Bellinzona, Surgery, Switzerland

Background: Gastrointestinal Stromal Tumors (GISTs) are rare neoplasias that occur throughout the entirety of the GI tract but they most commonly present in the stomach (60%) or small intestine (20% to 30%). They originate from mesenchimal stem cells, progenitors of interstitial cells of Cajal, normally responsible for intestinal peristalsis. In Caucasian populations their annual incidence is 10 to 15 cases per million and approximately 30% of GISTs are malignant. Surgery is the standard treatment of local GIST. We describe here the case of a 49 years old male presenting with an emoperitoneum due to a large bleeding GIST of the gastric fundus.

Method: A 49 years old male, without previous pathologies, presenting with acute abdominal pain associated with hypotension. Once haemodynamic stability has been achieved, He is investigated with CT scan revealing abundant hemoperitoneum deriving from a 11 × 12x13 cm bleeding omental mass attached to the gastric fundus. The patient is taken to the operating room for laparoscopic resection of the mass and wedge resection of the gastric fundus.

Results: The intervention was carried without intraoperative complications. The patient had a good postoperative course. Discharge was on the seventh postoperative day.

Histological examination resulted in a GIST with a risk class of moderate progression according to the Miettinen classification.

Conclusion: In the case presented, laparoscopic approach of local GIST is a safe and effective method for the surgical treatment of GIST.

ROBOTICS & NEW TECHNIQUES—Solid organs

V026—Laparoscopic left adrenalectomy for hyperfunctioning pheochromocytoma in a 25 weeks pregnant patient

Valentina Messina, A. Ida, E. Cassinotti, L. Baldari, L. Boni

¹Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy, Department of Surgery, Italy

Aims: This video shows our experience and technique to perform a left laparoscopic adrenalectomy in a pregnant woman with hyperfunctioning pheochromocytoma.

Methods: This is a case of a 31-years-old pregnant woman at 25 weeks gestation complaining for severe headaches with recent diagnosis of hypertensive crisis. An abdominal ultrasound (US) and a magnetic resonance imaging (MRI) without intravenous contrast agent were performed, revealing a 7 cm lesion of the left adrenal gland. A 24-h urine sample demonstrated elevated vanillymandelic acid (VMA) and metanephrine levels; endocrinologist confirmed diagnosis of pheochromocytoma. After multidisciplinary team consultation and literature revision, due to high risk of serious complications potentially terminating pregnancy, patient was scheduled for a laparoscopic left adrenalectomy. The patient was placed on the right flank, pre-operatively a good fetal function was confirmed with an US fetal monitoring. 4 trocars were placed: a 11 mm in left subcostal zone, a 12 mm in left flank, two 5 mm in subxiphoid and left anterior axillar line. Wide mobilization of splenic flexure and spleen was performed in order to expose the left adrenal fossa. Lesion has been dissected from the pancreatic tale and the splenic hilum with advanced energy device; the main adrenal vein, originating from renal vein, was identified, isolated and dissected with linear stapler with vascular cartridge. Hypotensive blood pressure response was promptly controlled by anaesthesiologists. After complete dissection, the specimen was extracted through an endobag using a 5 cm mini-laparotomy in the left iliac fossa, in order to preserve suprapubic region for an eventual caesarean section. US fetal monitoring within normal limits was reported at the end of procedure.

Results: Postoperative course was uneventful and patient was discharged on postoperative day 10, after blood pressure and electrolytes fully normalized. Histopathological examination confirmed the diagnosis of adrenal pheochromocytoma, PASS score 5.

Conclusion: Surgical treatment of adrenal hyperfunctioning pheochromocytoma during pregnancy, although challenging, could be recommended to preserve mother and fetus health. Literature revision reports that early detection and management has shown improvements in fetal outcome. Multidisciplinary approach is essential. Minimally invasive technique performed by experienced surgeons could minimize surgical distress and allow faster post-operative recovery.

ROBOTICS & NEW TECHNIQUES—Technology

V027—Indocyanine green, a boon for VATS thymomectomy in thymomatous myasthenia gravis.

A. Bhandarwar¹, Balamurugan Ganesan ¹ , G. Bakhshi¹, R. Gajbhiye², A. Wagh¹, S. Jadhav¹, A. Tandur¹, S. Bhondve¹, N. Dhimole¹, K. Reddy¹, G. Bharadwaj¹, R. Bhat¹, A. Dutt¹, H. Padekar¹

Grant Government Medical College and Sir JJ group of hospitals, General Surgery, India, ²Government Medical College, Nagpur, General Surgery, India

Aims: Myasthenia gravis (MG) is an autoimmune disease manifested by fluctuating weakness and fatiguability. Thymoma is reportedly found in 10–30% of patients with MG. The purpose of this study is to investigate the feasibility of unilateral video-assisted thoracoscopic (VATS) thymomectomy in thymomatous MG.

Methods: The present study was conducted over a period of 4 years. The study included those with symptomatic thymomatous MG, pre-operative QMGS (Quantitative Myasthenia Gravis Scale) score more than 10, patient worsening on immunosuppressants. The exclusion criteria being Non-thymomatous MG, MG worsening secondary to concurrent medications, infections and other disorders causing weakness. All patients underwent unilateral (VATS) thymomectomy with intra-operative use of Indo-cyanine green (ICG) dye. The following data was analyzed: age, medical treatment prior to thymomectomy, pre-operative and post-operative QMGS scores, requirement of steroids and recurrence of symptoms. The patients were followed up every 3 months for a period of 3 years.

Results: A total of 18 patients were included in the study. All patients(n = 18) presented with generalized weakness with fatigue on repeated activity and drooping of eyelids. 7 of the patients presented with breathlessness, which were managed with non-invasive ventilation. All the patients were subjected to unilateral VATS thymomectomy (Fig. 1 showing intra-operative picture of thymoma) with intra-operative use of ICG dye and fluorescence. There was 71.04% percent improvement in the QMGS scores and all were steroid independent at the end of 3 months. Myasthenic crisis was noted only in one patient post-operatively which was managed with steroids. There was no recurrence of myasthenic symptoms in the 3-year follow-up period.

Conclusions: Fluorescence imaging helps identify bilateral phrenic nerves by visualizing the pericardiophrenic neurovascular bundle, potentiating maximal excision of thymic tissue via a unilateral approach. Video assisted technique provides a magnified image of the neurovascular structures, which further prevents nerve injury. VATS thymomectomy gives comparable results to total thymectomy in thymomatous MG, with the added advantage of being less time consuming. As with other minimally invasive surgeries, there is less post-operative pain, faster recovery and preservation of pulmonary functions which is of utmost importance to a myasthenic patient. However, unilateral approach must be reserved for those with thymomatous myasthenia gravis, as patients with non-thymomatous MG require bilateral extended thymectomy.

ROBOTICS & NEW TECHNIQUES—Colorectal

V028—Laparoscopic left colectomy for benign diverticular stenosis using DEX articulating instruments and CREX compression anastomosis device

Alessandra Ida, F. Centonze, L. Baldari, E. Cassinotti, C. Manzo, L. Boni

¹Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Department of Surgery, Italy

Aim: This video shows our technique to perform a laparoscopic left colectomy using DEX Surgical articulating instruments and CREX compression anastomosis device.

Methods: The patient is a 62-year-old woman affected by recurrent acute diverticulitis of sigmoid colon diagnosed through colonoscopy and contrast enhanced abdominal CT scan. The patient was scheduled for a laparoscopic left colectomy with four trocars, using DEX Surgical articulating instruments and CREX compression anastomosis device. The mesentery of the colon was mobilized dividing the sigmoid arteries and the inferior mesenteric vein between clips. After dissection of Toldt’s fascia, lateral mobilization of the descending colon and splenic flexure mobilization were performed. The mesocolon dissection and colon mobilization were performed through the DEX Surgical articulating instruments, allowing surgeon’s wrist mobility with seven degrees of freedom thanks to motorized and mechanical motions. The upper rectum was divided using an articulated linear stapler. A sovrapubic mini-laparotomy was performed and colon extracted. After completing division of the mesentery, perfusion control of descending colon was checked with indocyanine green fluorescent angiography. A colo-rectal anastomosis was fashioned using C-REX RectoAid 26. After fashioning the anastomosis, a tool of the C-REX RectoAid is kept in place allowing an intense compression between colon and rectum with consequent healing of bowel walls at the level of anastomosis. This compression results in an end-to-end colorectal anastomosis. Anastomotic pressure was verified by a RectoAid device, through catheters.

Results: The post-operative course was uneventful and the patient was discharged on post-operative day six. Anastomotic pressure monitoring was carried out for six days after surgery showing no anomalies. After 10 days, the tool was naturally eliminated during evacuation. After 30 days, a flexible recto-sigmoidoscopy showed a complete healing of the anastomosis.

Conclusions: The use of DEX Surgical articulating instruments ensures precision, thanks to seven degrees of freedom, reducing instruments conflict. The C-REX compression anastomosis device allows to perform a safe anastomosis through the possibility to control anastomotic pressure after surgery.

ROBOTICS & NEW TECHNIQUES—Liver

V030—Robot-assisted Liver Resection for Posterior Segments

Graziano Ceccarelli ¹ , F. Ermili¹, W. Bugiantella¹, A. Bartoli², M. De Rosa¹, F. Arteritaano¹, A. Spaziani², F. Rondelli³

¹San Giovanni Battista Hospital, General Surgery, Italy, ²San Matteo Infermi Hospital, General Surgery, Italy, ³University of Terni, General Surgery, Italy

Background. Minimally invasive liver resections gained acceptance in the last 2 decades, demonstrating to be safe and feasible for malignant liver lesions too, in selected patients as reported at Luisville and following minimally invasive international conferences. Laparoscopy is today indicated not only for peripheral segments (2, 3, 4b, 5, and 6), but for the posterior segmnets too as estabilished at Southampton conference, even it is indicated in selected expert centres or by expert surgeons. Diffusion of robotic liver surgery, seams to represent an interesting assistance for challenging minimally invasive liver resections for example the postero-superior segments.

Materials and methods Between January 2012 and November 2021, 155 robotic-assisted hepatectomies were performed by our team in two hospitals (San Donato Hospital, Arezzo & San Matteo Hospital, Spoleto—Italy). 67 patients (43%) presented a tumor localization in a conventional challenging laparoscopic segment (segment 1, 4a, 7 and 8), excluding the major hepatectomies. In those cases a wedge (82%) or anatomical segmnetal resection was performed.

The video shows the main surgical steps of any cases of robot-assisted liver resections. Pringle maneuver, ultrasound lesion identification, parenchima resection and ICG use are illustrated.

Conclusions. About parenchymal-sparing liver surgery, especially for challenging posterior segmnets, robotic technology offers clear advantages compared to conventional laparoscopy in terms of better view, good bleeding control during transection, esier liver pedicle nodes dissection and bile duct management (when request). Those thanks to instruments articulation and precision of movements, useful for intracorporeal micro-sutures when necessary.

ROBOTICS & NEW TECHNIQUES—Pancreas

V031—Robot-assisted Radical Antegrade Modular PancreatoSplenectomy (RAMPS) for NeuroEndocrine Tumor (NET) of the pancreatic body, with intraoperative ICG-fluorescence angiogra

Diego Coletta, F. Petrelli, A. Patriti

¹Azienda Ospedaliera Ospedali Riuniti Marche Nord, Chirurgia Generale, Italy

We present a case of a 72 years-old woman admitted to our Surgical Department with a diagnosis of a neuroendocrine tumor of the pancreatic body. A CT scan made to follow-up an abdominal incisional hernia has shown a 25 mm cystic mass of the pancreatic body. The preoperative workup included an abdomen MRI and an Endoscopic Ultrasound (EUS) in association with a biopsy of the lesion.The pathological findings had shown NET.No liver nor thoracic mestastases were found on staging CT scan. After a multidisciplinary meeting discussion, a minimally invasive pancreatosplenectomy was indicated and the patient underwent robot-assisted RAMPS wih Da Vinci Xi System.

The video shows the surgical procedure step by step with the application of intraoperative ICG-fluorescence angiography and robotic ultrasound to evaluate the borders of surgical resection and eventual vascular involvement.The duration of surgery was 255 min.

SOLID ORGANS—Thyroid

V032—Expanding Applications for Fluorescence Guided Surgery

Ariel de Jesùs Martìnez Oñate, V. Càzares Garcìa, A.J. Martìnez salas

¹Hospital Àngeles del Pedregal, Surgery, Mexico

Taking advantage of the versatility and increasing availability of Flueorescence Guided Surgery ( using Indocyanine Green (ICG-FGS) we have applied it`s use for different surgical procedures in head and neck surgery and esophageal surgery for benign pathology. Some of these applications have not been described before. We show ICG-FGS for the confirmation of complete resection and abscence of residual bleeding after surgery for a carotid body tumour Shamblin II—III. For the visualization of the right thoracic duct during a Thyroidectomy and lymph node resection for an advanced papillary thyroid cancer surgery, and for the visualization of the integrity of the esophageal wall after the complete dissection of the distal esophagus during a Nissen fundoplication for the treatment of GERD. This last case as an excercise for a future Heller miotomy in another patient.

We believe that expanding applications of ICG-FGS are a fact and once their feasibility and usesfulness is demonstrated they must be subjected to large trials and RCT.

SOLID ORGANS—Adrenal

V033—Unilateral Laparoscopic Adrenalectomy for Micronodular Adrenal Hyperplasy in a 3 years-old patient—A rare clinical case

Mário Rui Correia ¹ , P. Marinho², J. Barbosa-Sequeira¹, C. Carvalho¹, J. Asworth¹, T. Borges³, J. Ribeiro Castro¹, F. Carvalho¹

¹Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Pediatric Surgery, Portugal, ²Unidade Local de Saúde do Alto Minho, Viana do Castelo, Pediatrics, Portugal, ³Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Pediatric Endocrinology, Portugal

Aims: Cushing’s syndrome (CS) is a rare condition in children. Exogenous iatrogenic exposure to glucocorticoid remains the most common cause of CS in paediatric patients. Pituitary-dependent Cushing’s disease is more frequent in children older than 5 and is the commonest form of CS in childhood and adolescence. In contrast, infants are more likely to have a primary adrenal condition. Rarer causes (~ 2%) of ACTH-independent CS include primary bilateral adrenocortical hyperplasias (PBAH); which include primary bilateral macronodular (PBMAH) and micronodular adrenal hyperplasias (MiBAH), which are subdivided in primary pigmented nodular adrenocortical disease and isolated micronodular adrenocortical disease (i-MAD).

Methods: Herein we present a 3 years-old male child who presented with a 3-month history of growth failure, weight gain, hirsutism, and moon facies. Elevated serum, salivary and urine cortisol levels were confirmed linked with undetectable ACTH levels. Magnetic resonance imaging described an “hyperplasic left adrenal gland” (Fig. 1). No abnormalities were recognized with (FDG)PET/CT imaging (Fig. 2).

Results: Due to his severe hypercortisolism, metyrapone—a steroidogenesis inhibitor—was used transiently preoperatively. A left transperitoneal laparoscopic adrenalectomy was performed with patient positioned in a right lateral decubitus. After mobilization of the splenic flexure and spleen, the left adrenal vein was dissected and secured. Adrenal gland was withdrawn, and beside its subjective bigger size, no macroscopic changes were reported. A Pezzer drain was placed and removed in the first post-operative day. No intra-operative complications were reported. Patient made an uneventful recovery, being discharged on the sixth post-operative day. Histological examination revealed multiple less than 5 mm nodules, non-pigmented, establishing the diagnosis as a i-MAD.

To present day, the patient has a two-month follow-up in endocrinology consult, still under corticoid supplementation, with normal urinary cortisol levels and considerable clinical improvement.

Conclusion: MiBAH presents as a challenge in diagnosis and dilemma in treatment as the young patients will live with the consequences of their treatments for most of their lives.

One-stage radical surgical removal of both adrenals is standard for PBAH and the most frequently used therapy to cure MiBAH patients with CS. Recent data on unilateral adrenalectomy suggests that this approach could be considered.

SOLID ORGANS—Adrenal

V034—Laparoscopic Giant Adrenalectomy: Does Size Matter?

Mariangela Ilardi, N. Pirozzi, B. Iacone, R. Peltrini, A. Coppola, U. Bracale, F. Corcione

¹Università degli studi di Napoli Federico II, Public Health, Italy

Large adrenal tumours (LATs) range in size from more than 5 to 10 cm in diameter.

Laparoscopic adrenalectomy (LA) is the standard approach in benign adrenal masses and is routinely performed in masses smaller than 5 to 7 cm. Usually in case of adrenal masses size more than 5 cm, minimally invasive procedures are contraindicated due to the possibility of malignancy and the technical difficulties of the surgical procedure. Thus, in these cases open adrenalectomy (OA) is usually preferred. We show the feasibility, effectiveness, and the safety of a laparoscopic approach also in case of giant adrenal masses. However, it should only be performed by skilled surgeons in laparoscopic surgery.

Methods: This video shows a standardized and reproducible technique with anatomical landmarks for those surgeons who want to approach laparoscopic giant adrenalectomy. Clinical case is a large palpable mass sited in the left hypochondrium. Computed tomography scan (CT) was suggested of giant adrenal mass(15 × 12x7 cm, Fig. 1.2.). results. Operative time was 150 min and no intraoperative blood loss was recorded. The final scare length measured 4 cm.Recovery was uneventful and the patient was discharged 3 days after surgery. Pathological repost showed an adrenal carcinoma.Postoperative follow-up was negative for recurrence at 18 months.

Conclusions:Laparoscopic adrenalectomy is a safe, feasible and effective method to performing minimally invasive adrenal surgeries also in case of giant adrenal masses. In this case, a laparoscopic approach showed minimal morbidity, short convalescence, and similar outcomes compared with open surgery. However, to laparoscopically approaching giant adrenal masses, high expertise in laparoscopy and in adrenal surgeries are required.

SOLID ORGANS—Adrenal

V035—Laparoscopic resection of retrocaval schwannoma

Dusan Lesko, M. Soltes, J. Radonak

¹University Hospital UNLP and LF UNLP Kosice, 1st Department of Surgery, Slovakia

We report a case of a successfully resected retroperitoneal benign schwannoma using laparoscopic surgery. A 62-year-old man presented with an asymptomatic retroperitoneal mass. Computed tomography and magnetic resonance scan revealed a solid tumor between vertebrae L5 and the inferior vena cava (IVC)—see Image 1 and 2. We realized the complete laparoscopic resection of the tumor with size of 28 × 24x32 mm. Pathology revealed a benign schwannoma. The clinical course was uneventful, and the patient was discharged on postoperative day 3 without any complications. Here we report this rare case of a retrocaval schwannoma. In our case, despite the localization of the tumor behind the IVC, a totally laparoscopic resection was feasible.

Key words: laparoscopy—retroperitoneal—retrocaval—schwannoma.

SOLID ORGANS—Adrenal

V037—Laparoscopic transperitoneal right adrenalectomy for large adrenal tumor.

Maciej Matyja, P.M. Major, P.M. Pędziwiatr, A.M. Matyja

¹Jagiellonian University Medical College, 2nd Department of General Surgery, Poland

Introduction: Laparoscopic adrenalectomy has become a golden standard. However, it may remain controversial in case of large lesions. Proper oncological technique in laparoscopy is more challenging because of a higher risk of capsule injury. Nevertheless, in. the hands of an experienced surgeon it can be performed with safety.

Aim: The aim of this video is to demonstrate the application of laparoscopic surgery for the treatment of large malignant adrenal tumors.

Methods: Patient is a 51 year- old male with right adrenal incidentaloma 12 cm in diameter, with no hormonal activity. There was no infiltration of surrounding organs, no lymphadenopathy and no distant metastases found preoperatively. The patient was scheduled for laparoscopic right adrenalectomy (lateral transperitoneal approach). After positioning our patient in left lateral decubitus, ports were placed inferior to the costal margin. The right lobe of the liver was mobilized, the inferior vena cava was exposed and dissected. The adrenal vein was identified, dissected, double-clipped, and divided. The tumor was then dissected circumferentially and was removed without injuring its capsule in an endoscopic retrieval bag. 5 mm lesion of the peritoneum in the area of hepatic flexure was removed to exclude peritoneal dissemination of the tumor.

Results: Patient tolerated the procedure well, had no issues with hemodynamic stability and blood pressure was within normal ranges during and following the case. The pathology report confirmed R0 resection of oncocytic adrenal tumor of uncertain malignant potential and mesothelial-lined peritoneal cyst.

Conclusion: In the hands of an experienced surgeon laparoscopic adrenalectomy for large adrenal tumors is efficient provides analternative to open surgery.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V038—Benign biliary stricture post cholecystectomy—laparoscopic approach for biliary metal stent removal and choledochoduodenostomy

R. Peixoto, Catarina Mesquita Guimarães, A.F. Rocha, C. Mesquita Guimarães, P. Soares Moreira, G. Faria

¹Unidade Local de Saúde de Matosinhos, General Surgery, Portugal

Benign biliary stricture is a possible complication after cholecystectomy.

Nowadays, the first treatment option should be the endoscopic/percutaneous strategy with initial dilatation and insertion of a biliary stent, if necessary.

Surgical treatment is reserved for selected patients, generally those with a low surgical risk with recurrent infections.

We report a 67 year old male patient admitted in our hospital 2 years prior this event with cholangitis. As background medical history he had a total gastrectomy for gastric cancer 20 years ago. After medical treatment with antibiotics for cholangitis, the patient was submitted to cholecystectomy. Due to adhesions of prior surgery, the surgery was converted to laparotomy and biliary exploration was done. Due to two more events of cholangitis after surgery, it was required a magnetic resonance cholangiopancreatography showing a distal stricture of the main biliary duct, without stones or nodules. Several exams were done to exclude malignancy. Since the patient refused another surgery and had a Y-en-Roux anastomosis, the endoscopic access wasn’t an option and a metallic stent was placed percutaneously by interventional radiology. In 2021, the patient was admitted again with cholangitis with intrahepatic biliary tree dilation, compatible with stent occlusion. Finally, the patient accepted another surgery. The present video shows the laparoscopic approach, after two laparotomies with several adhesions, of the extrahepatic biliary tree with the removal of the metallic stent and confection of a choledochoduodenal anastomosis.

Postop was complicated with an abdominal collection drained percutaneously and treated with antibiotics for the bacteria isolated in bile specimen.

Metallic stents, usually used in malignant disease, have been used in benign biliary strictures as an alternative to plastic stents reducing the number of procedures with good efficacy. However, the stent obstruction rate in long term is not negligible and some patients, such as this case, are submitted to major surgery. The high risk of complications and technical challenges during this laparoscopic surgery demands an experient surgical team.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V039—Laparoscopic cholecystectomy for porcelain gallbladder

Marek Soltés, D. Lesko, J. Radonak

¹Pavol Jozef Safarik University in Kosice, 1st Department of Surgery, Slovakia

Porcelain gallbladder traditionally represents a relative contraindication to laparoscopic cholecystectomy. This is mainly due to the expected technical difficulties leading to potential intraoperative complications and conversion as well as percepted increased risk of malignancy. While coincidence of gallbladder cancer and porcelain galbladder is reported controversially, intraoperative difficulties due to hyalinization and sclerotization of the gallbladder wall are reality. As a result, some technical modifications are needed to achieve successful laparoscopic cholecystectomy that may be benefitial for patients with porcelain gallbladder due to its diagnostic potential and minimally invasive nature. Authors present a video of the successful laparoscopic cholecystectomy for porcelain gallbladder highlighting some principal technical hints.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V040—Laparoscopic Pancreatico-duodenectomy following laparoscopic left colectomy in a patient with Lynch syndrome

Gil Faria, F. Marrana, T. Moreira Marques, R. Peixoto, P. Soares Moreira

¹Unidade Local de Saúde de Matosinhos, General Surgery, Portugal

Background: Lynch syndrome is associated with increased risk of colo-rectal cancer and malignancy of the stomach, small bowel and pancreas among others. Identifying MMR mutations allows patients to start on early screening programs and leads to diagnosis of pre-malignant lesions.

Clinical Case: We present the case of a 36 years-old male with a known MMR mutation. Due to screening he was diagnosed with a high-grade dysplasia in the left colon 2 years prior and underwent a laparoscopic left hemicolectomy. The surgery was uneventful. On following screening examinations (Upper Digestive Endoscopy) he was diagnosed with a 6 cm adenoma of the duodenum, just next to Vater’s papilla with a biopsy-proven high-grade dysplasia. The patient was evaluated on the multidisciplinary tumour board and proposed for laparoscopic pancreatico-duodenectomy. The surgery was uneventfull and the patient was discharged on the 8 th post-operative day. We present the video of this surgery, emphasizing the anatomical changes imposed by the previous colectomy (omentectomy, high ligation of lower mesenteric vein) and the increased challenge of a duct-to-mucosa pancreatico-jejunostomy with a non-dilated pancreatic duct.

Conclusion: Previous abdominal surgeries are not a contra-indication to laparoscopic pancreatico-duodenectomy but surgeons must be aware of the potential changes of anatomical landmarks.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V041—Laparoscopic Distal Pancreatectomy for Necrotizing Pancreatitis

Maher Hussein

¹American University of Beirut Medical Center, Surgery Department, Lebanon

The video will show the steps used to treat infected, necrotizing pancreatitis where release of adhesions followed by distal pancreatectomy using hydro dissection. Patient had smooth post-operative course and was discharged 48 h post surgery.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V042—The reconstruction of extrahepatic bile ducts on a T-shaped drain in cases of injury MBD type 1, Me, P, Ep (ATOM classification).

Vadym Ilyashenko, V. Grubnik, V. Grubnyk, S. Parfentiev, P. Nikitenko, V. Mishchenko, A. Koyichev

¹Odessa National Medical University, Surgery, Ukraine

Since 1993, the Odessa Regional Clinical Hospital has been a center for the treatment of damage to the extrahepatic bile ducts. During the period from 1993 to 2021, we treated 32 bile duct injuries. All lesions of the extrahepatic ducts were analyzed and classified according to the “ATOM” system recommended in 2013 by EAES.

From 1993 to 2013, the main bile duct injury was MBD2, 19 (73.0%) out of 26, during this period, and 59,4% of the total number of patients.

Since 2013, the main bile duct injury was MBD1, 5(83,3%) out of 6, 15.6% of the total number of patients.

These were mainly mechanical injuries associated with a violation in the technique of clipping the cystic duct(Me -mechanical(ATOM)). With such injuries, the posterior wall of the common bile duct remained intact(P—partial(ATOM). In the early postoperative period (up to 7 days, (Ep—early postoperative(ATOM)), this circumstance made it possible to perform plastic surgery of the common bile duct using a T-shaped drainage drain. We performed reconstructive surgery of the extrahepatic bile ducts on a T-shaped drainage in 5 patients with MBD 1, Me,P,Ep. All patients were discharged on days 14–16 after surgery without complications. The T-shaped drain was removed 4 months after surgery. We did not observe stenosis of the extrahepatic bile ducts in these patients during 2 years. On the video, we show a variant of the operation.

Conclusion: Plastic surgery and reconstruction of extrahepatic bile ducts on a T-shaped drain is possible in case of damage of the MBD type 1, Me, P, Ep.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V043—Laparoscopic spleen-preserving total pancreatectomy with iatrogenic injury to splenic artery

Tomasz Wikar, A. Zub-Pokrowiecka, J. Kulawik, B. Staszczak, J. Rymarowicz, A. Matyja, M. Pędziwiatr

¹Jagiellonian University Hospital, 2nd Department of Surgery, Poland

Nowadays, classic approach is still a method of choice while performing total pancreatectomy. Taking into consideration advantages of minimally invasive surgery (MIS) with widespread use of laparoscopic approach in gastrointestinal tumor resections, pancreatic surgeries become more feasible due to increasing expertise in MIS. Recently incidence of Intraductal pappilary mucinous neoplasms (IPMNs) has increased due to improvement in diagnostic tools. Occurrence of synchronous or metachronous IPMNs is approximately 20%.

We present a case of 72yo female with two masses, one in pancreatic head and second in pancreatic body. Endoscopic ultrasonography with biopsy confirm IPMN- intestinal type with low grade dysplasia. Considering the locations of the lesions and concomitant diabetes mellitus patient was scheduled to laparoscopic total pancreatectomy.

This video presents step by step approach to laparoscopic spleen-preserving total pancreatectomy with iatrogenic splenic artery injury and its suturing.

Postoperative course was uneventful. Colour Doppler Ultrasonography confirmed flow in splenic artery.

COLORECTAL—Malignant

V044—Transal Total Mesorectal Excisoin (TaTME) for stenosing cancer of the mid rectum with ICG assessment of the anastomosis

Andrea Biancucci, A. Fassari, M.M. Lirici

¹San Giovanni Addolorata Hospital Complex, Department of Oncologic Surgery, Italy

Aim: Transanal TME (TaTME) is a relatively new approach to rectal cancer treatment. The intraoperative use of Indocyanine green (ICG) fluorescence imaging enables a close endoluminal check of the anastomosis and may be a helpful tool to avoid useless diverting ileostomies.

Materials and Methods: This is the case of a 90-year, otherwise well-being man, with rectal bleeding and increasing obstructive-type symptoms. Colonoscopy detected a stenosing mass in the upper rectum, at 10 cm from the anal verge (AV). Histology showed an infiltrating adenocarcinoma. Pelvic MRI and abdominal CT-scan showed a bulky rectal cancer, no distant metastases and an intact mesorectal fascia. TaTME was performed with one-team, two-step, laparoscopic-first approach. First, the high ligation of the inferior mesenteric vein and artery were performed, after medial-to-lateral mesocolon dissection and complete splenic flexure mobilization through laparoscopy. The pelvic dissection was furthered according to the Total Mesorectal Excision (TME) principles, entering the holy plane down to the level of the puborectal sling posteriorly and that of the seminal vesicles anteriorly. The transanal step was performed after placement of the access platform GelPoint connected to the Airseal insufflation system. A purse-string was fashioned a couple of centimeters below the tumor, a full-thickness circumferential rectotomy was then carried out and the correct mesorectal plane identified and entered. Dissection is carried on by HF hook with care not to injury the mesorectal fascia up to the level of the laparoscopic dissection. The bulging specimen was extracted through a suprapubic mini-laparotomy. A transanal end-to-end stapled anastomosis was performed at about 5 cm from the anal verge. Five ml of ICG solution was intravenously injected to confirm the anastomotic perfusion. An optimal greenish tissue diffusion allows not to construct a diverting ileostomy to protect the anastomosis.

Results: Total operative time was 300 min. Postoperative course was uneventful recovery and the patient was discharged on postoperative day 7. The pathology report showed a moderately differentiated invasive adenocarcinoma that was staged as pT3 (invasion of perirectal fat), pN0 (0 out of 12 nodes harvested/examinated), Quirke completeness score of mesorectal fascia: complete, distal proximal and radial margins free, R0 resection.

Conclusions: Transanal TME (TaTME) combines mini-invasiveness of the laparoscopic abdominal and transanal approaches, allowing both close resection margins and good quality TME. It is a feasible surgical technique even when a Cecil approach cannot be available and offers promising good results in terms of post-operative and oncological outcomes. Indocyanine green (ICG) fluorescence imaging has been proven to be an effective tool to assess anastomotic perfusion. Its use let surgeon optimize the procedure avoiding useless protection ostomies.

COLORECTAL—Malignant

V045—Intracorporeal ileal pouch anal anastomosis during fully laparoscopic total proctocolectomy with trans-anal specimen extraction

Lorenzo Bernardi, A. Cristaudi, R. Roesel, D. Christoforidis, S.G. Popeskou

¹Ospedale Regionale di Lugano, Department of Surgery, Switzerland

Background: Total proctocolectomy (TP) is the backbone of surgical treatment of severe ulcerative colitis (UC) and familiar adenomatous polyposis (FAP). Laparoscopic approach has gained wide consensus for TP among colorectal surgeons, but a small laparotomy is usually used to extract the specimen and to create the ileal pouch manually before the mechanical ileal pouch anal anastomosis (IPAA).

Methods: We present a step-by-step technique of intracorporeal IPAA after fully laparoscopic TP with trans-anal specimen extraction in a case of young woman affected by FAP.

Procedure: One 11 mm umbilical optic port, three 5 mm working port in right and left lower abdomen (clavicular line) and in right flank are placed. TP is carried out in a standard fashion starting with mobilization of the rectum first and then proceeding cephalad to the sigmoid-left-transverse and right colon. The ileum and its mesentery are divided just before the ileo-cecal junction, the rectum is divided 1.5 cm above the dentate line under direct-finger control and the specimen is extracted trans-anally. The pouch anastomotic site is then marked testing the tension to achieve maximum length. The peritoneum is opened at the tension point along the superior mesenteric vessels (SMVs) root.

To create the J-pouch a small enterotomy is performed 15 cm distant from the ileal stump (future pouch apex). A side-to-side mechanical anastomosis is done by firing three linear GIA 60 mm stapler trough the enterotomy while carefully keeping away the mesentery. The remnant blind loop of the J-pouch is resected to avoid blind loop syndrome.

The anvil of the circular stapler is inserted in the opened pouch apex; the latter is tied with a purse-string suture. The pouch is placed into the pelvic floor to test for sufficient length. Peritoneal release is performed through vertical incisions along the peritoneum covering the SMVs to gain as much length possible and to avoid tension. The endoscopic stapler gun is inserted trans-anally, an IPAA is done. Indocyanine green perfusion test is used to test IPAA perfusion. Finally, a diverting ileostomy loop is created.

Conclusion: Intracorporeal IPAA after fully laparoscopic TP with trans-anal specimen extraction is feasible and safe.

COLORECTAL—Malignant

V046—Laparoscopic Right Colectomy with D3 Lymphadenectomy and Complete Mesocolon Excision guided by Indocyanine Green for Right Colonic Cancer

Eugenio Licardie ¹ , I. Alarcón², A. Tejada³, A. Senent², L. Navarro³, S. Morales-Conde²

¹Quironsalud Sagrado Corazón, Infanta Elena Hospital, Department of General and Digestive Surgery, Spain, ²University Hospital Virgen del Rocio, Seville, Unit of innovation in Minimally Invasive Surgery And Unit of General and Digestive Surgery, Spain, ³Quironsalud Sagrado Corazón, Seville, Unit of General and Digestive Surgery, Spain

Aims: Complete mesocolon excision (CME) and D3-lymphadenectomy have been shown to provide superior oncological outcomes and better survival advantages in patients with right colon cancer stages I–III. More extended lymphadenectomy for right colon cancer is suggested because 4%–5% of patients have previously been reported to have metastatic lymph nodes in an unusual site, such as above the head of the pancreas or along the gastroepiploic vessels, or the left branch of the middle colic vessels, caused by the variation in lymphatic flow of the right colon.

Methods: Lymphatic flow may vary and can be uncertain. Therefore, an intraoperative real-time laparoscopic observation of the lymph flow of this area using indocyanine green (ICG) fluorescence imaging can be helpful in identifying the appropriate central vessels to be dissected and for determining the appropriate surgical plane of the mesentery.

Results: Here, we present the case of a 50-year-old female with a history of lower right quadrant abdominal pain, which led to an abdominal CT-scan and colonoscopy being performed. This revealed a nonocclusive tumor of 3 cm in the caecum, with a histopathology of adenocarcinoma, pT3N2bM0, IIIB-stage. Laparoscopic right colectomy with D3-lymphadenectomy guided by ICG and CME was subsequently performed.

Conclusions: This Video demonstrates the utility of the intraoperative injection of ICG in the colonic wall in visualizing the lymphatic flow of the tumor, which helps us to perform an optimal and tailored lymphadenectomy and CME. Also, we corroborate the use of the ICG in confirming good perfusion and viability of the remaining bowel after resection, minimizing the risk of anastomotic leakage.

COLORECTAL—Benign

V047—Management of diverticulitis with colo-vesical fistula

Y. Nishihara, Ryo Miazaki, R. M. Miazaki, A. Y. Ando, K. N. Nagakari, K. H. Hiramatsu, Y. F. Fukui, Y. H. Hanaoka, S. T. Toda, M. U. Ueno, H. K. Kuroyanagi, S. M. Matoba

¹Toranomon Hospital, Digestive Surgery, Japan

Background: Recently in Japan, Western style of living has increased the numbers of sigmoid diverticulitis. 25% of Acute Diverticulitis are complicated type such as the abscess, perforation, fistula, and obstruction. Colo-vesical fistula (CVF) is the most common type of fistula of diverticular disease. Since fistulas due to diverticulitis rarely close spontaneously, surgery is required.

CVF is the most challenging hurdle in fistula associated with diverticulitis.

Laparoscopic surgery enables meticulous dissection with a magnified surgical view and is suitable for colorectal surgery. Therefore, we introduced laparoscopic surgery for complicated diverticulitis.

Method: Our patients underwent colonoscopy, CT or MRI to confirm CVF and to exclude colorectal cancer. Cytoscopy was also performed to confirm patency of bilateral ureteral orifices and to exclude urological malignancies. The surgery was performed at least four weeks after recovery of acute diverticulitis. We basically use 5 ports and 10 mm flexible 3D scope to operate. In our experience, fistulas caused by sigmoid diverticulitis result in spreading pericolic inflammation that forms an abscess cavity, eventually penetrating the bladder. Therefore, sigmoid colon diverticula connects to the bladder through an abscess cavity. For this reason, the best way to divide the colon and bladder is to incise the abscess cavity. In most cases the fistula can be removed without opening the bladder.

Results: From 2008 to 2021 we underwent 65 cases of the laparoscopic surgery for CVF. The Median age is 59 years old. The median operating time and blood loss are 215 min and 75 ml. There are no conversion to open surgery. Clavien-Dindo grade 3 postoperative complications included 1 case of abscess requiring percutaneous drainage and one case of left ureter injury requiring reoperation.

Conclusion: Despite these 2 cases of Clavien-Dindo Grade III complications, our series were safe and feasible.

COLORECTAL—Benign

V048—Technique of mini-laparoscopy assisted colonoscopy

K. Campbell^1,2, Ramy Shaalan ^1,2 , D. Kumar¹, S. Elbakri¹, T. Khalil¹, R. Shaalan^1,2

¹Ninewells hospital, General surgery, United Kingdom, ²Ain Shams University, Egypt, Colorectal Surgery, United Kingdom

This video demonstrates an approach to facilitating diagnostic and therapeutic colonoscopy in previously refractory cases. By tackling fixed angulation using 3 mm instrumentation, colonoscopic completion and polypectomy are facilitated. Maintaining integrity of the colonic wall and minimally breaching abdominal fascia are the key advantages with successful subsequent colonoscopy an added benefit.

Aim: Patients in whom colonoscopy cannot be completed, and imaging suggests a proximal lesion, present a dilemma. Resection may be excessive, surveillance leaves doubts, colotomy risks leakage and requires an extraction site. This video demonstrates the use of laparoscopy to facilitate an entirely endoscopic approach to a previously inaccessible polyp.

Methods: Optical entry off the midline using a 5 mm telescope. Two 3 mm minilaparoscopy instruments are introduced to take down adhesions. Fixed angulation at the rectosigmoid from previous surgery is confirmed and mobilisation undertaken. Colonoscope then negotiated through to the polyp. Injection, snaring, retrieval and tattooing all undertaken with laparoscopic monitoring.

Results: In 15 patients with fixed angulation preventing colonoscopy, laparoscopic assistance has allowed completion. Polyps were successfully retrieved in 12 cases and imaging proved wrong in another. In 10 cases follow up colonoscopy has been successfully completed under sedation. Morbidity has been insignificant and the majority processed as day patients.

Conclusion: A minimally invasive day case technique, which can solve dilemmas arising from failed colonoscopy, is demonstrated. Fixed angulation from previous surgery, a frequent cause, can be safely targeted, allowing an intralumenal approach to be maintained. This technique is a useful addition to the armamentarium of an active endoscopy service.

COLORECTAL—Benign

V049—Transanal Minimal invasive surgery approach for resection of polyps in the rectum, using indigo carmine, performing intermuscular resection

Gustavo Flores Flores, C.J. Chaves, A.N. Soler, A. Lopez Farías, P.F. Balaguer

¹Merida Hospital, General Surgery, Spain

Introduction Trans-anal approach for rectal polyps surgery is an increasingly performed surgery in our environment. It allows us to perform complete exeresis and studies of polyps with excellent resection quality, besides very fast postoperative recoveries. In addition, the pathology results show a lower rate of fragmentation, compared to those performed by colonoscopy.

Methods: We present two clinical cases in which the excision of polyps in the middle rectum and upper rectum is performed by transanal dissection. Case report 1: T1 middle rectum adenocarcinoma, studied by pelvic CT and magnetic resonance imaging. Resection of the lesion including mesorectum is performed, although there were no pathological adenopathies by image. After excision of the tumor, rectal mucosa closure is performed. Case report 2: Non-resectable tubulovillous polyp of the middle rectum, intermuscular resection is performed for the AP study, trying not to reach the mesorectum, with the subsequent closure of the mucosa through barbed sutures. We study the polyps in a protocolized way, since when they are detected by colonoscopy, they are tattooed and biopsied. After the results of pathological anatomy they are presented in the multidisciplinary committee for the approach. As these are large polyps that cannot be resected by colonoscopy in our center, they are candidates for transanal resection using a TAMIS approach. Depending on the pathological anatomy, it is decided to perform total excision of the polyp until reaching mesorrect in case of T1 adenocaricnomas, unlike the tubulovillous adenoma that we try to perform an intermuscular dissection to preserve the intact mesorrect.

Results: With this kind of approach we can achieve a very good disection of the polyp and a very good quality of the specimen, ocasionally we could have burn artifacts at the margins.

Conclusion: The minimally invasive transanal surgery allows us to perform an approach under direct vision of polyps with difficult resection by colonoscopy, which can be completely removed with adequate quality in the resection of their margins. Avoiding in the first instance having to perform major surgery for this type of polyps. Even in patients who after excision of a tubulovillous polyp where the mesorectum is respected, if in the future the patient would have an adenocarcinoma and had a TME, it would be performed with less technical difficulty by not generating fibrosis in the dissection plane.

ROBOTICS & NEW TECHNIQUES—Pancreas

V050—The use of indocyanine green in cephalo-pancreatic carcinoma: a way to improve the quality of resection?

F. Calabrese, Antonio Nieto, M.D. De Francesco, Q.G. Querini, A.C. Caneparo, T.R. Trapani, S.Z. Zonta

¹Ospedale Unico Plurisede VCO, General Surgery, Italy

Aims. The use of indocyanine green (ICG) in endoscopic surgery is increasingly widespread. ICG he is used to map lymph node drainage and to evaluate tissue perfusion but in pancreatic surgery its use remains limited. In this video we used the ICG to highlight the mesopancreas and the lymphatic spread of the cancer.

Methods. We are experiencing two methods to infuse the ICG in the pancreatic head:

· Multiple trans-duodenum injections performed by a lateral vision endoscope at the start of surgical procedure;

· An injection on anterior face and an injection on posterior face of pancreas’ head performed during surgery, after Kocher’s maneuver.

The fluorescence is used to guide the mesopancreas dissection and to highlight any remaining of lymphatic tissue.

Results: The video shows the procedures of ICG injection. The fluorescence highlights the mesopancreas that can be completely removed. In addition, the infra-red light, points out a fluorescence emission of the adipose tissue in the Gerota's fascia. We performed a biopsy of the tissue which would prove to be positive to angio-lymphatic invasion of the neoplasm.

Conclusion: The procedure of ICG injection in the pancreas head is safe and, easy to repeat and it takes only a few minutes. In our limited experience it can provide real help in the dissection of Mesopancreas and to identify any remains of Lymphatic tissue involved by the Neoplasm.

ROBOTICS & NEW TECHNIQUES—Technology

V052—The Wave of ICG in Minimal Access Surgery

A. Bhandarwar, Harshal Padekar, G. Bakhshi, R. Gajbhiye, A. Wagh, S. Jadhav, A. Tandur, S. Bhondve, K. Reddy, G. Bharadwaj, S. Dharmadhikari, A. Dutt, N. Dhimole, B. Ganesan, R. Bhat

¹Grant Medical College and Sir JJ Group of Hospitals, General Surgery, India

Aim: Dawned has the era of Indocyanine Green(ICG), and its extensive use in everyday operative procedures. This video is an amalgamation of an ongoing case series across various Gl/HPB and Endocrinal minimal access procedures done. ICG is a relatively nontoxic, unstable compound bound by albumin in the intravascular space until rapid clearance by the liver.

Methods: The present prospective study was conducted over a period of 5 years at JJ Group of Hospitals including various endoscopic and laparoscopic procedures like cholecystectomy,

nephrectomy, adrenalectomy, thyroidectomy and parathyroidectomy. Intraoperative and post operative parameters like duration of surgery, adverse intra operative events and past operative complications were included. Complicated and advanced laparoscopic procedures like surgeries for abdominothoracic hydatid cyst, bariatric surgeries and choledochal cyst excision with hepaticojejunostomy were also included. Various techniques of using ICG in these surgeries was also elaborated.

Result: Of the 219 patients studied, < 10% complication rates were witnessed. The surgeries were also associated with lesser intraoperative time and fewer incidence of intra operative and post operative, adverse events, in particular for laparoscopic cholecystectomy and laparoscopic adrenalectomy. ICG proved to be helpful in delineating vascular and biliary anatomy, providing real time fluorescence guided imaging of the same. As we progressed further with our experience of using novel CG techniques, the operative time and amount of ICG used further decreased.

Conclusion: ICG has revolutionized the real-time vascular and biliary mapping, thus permitting pinpoint dissection, hemostasis and evade biliary injuries. It is valuable in identifying aberrant vascular and biliary anatomy in difficult and unfamiliar surgical procedures. It is an extremely promising addition to the armamentarium making endoscopic procedures safer and more comfortable for the patient and the surgeon alike.

ROBOTICS & NEW TECHNIQUES—Bariatrics

V053—Robotic-Assisted Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy for Super-Superobese Patient

M. Raffaelli¹, Francesco Pennestrì ¹ , L.C. Ciccoritti², F.G. Greco², F.P. Pennestrì²

¹Fondazione Policlinico Universitario Agostino Gemelli IRCCS—Università Cattolica del Sacro Cuore, U.O.C. di Chirurgia Endocrina e Metabolica, Italy, ²Fondazione Policlinico Universitario Agostino Gemelli IRCCS, U.O.C. Chirurgia Endocrina e Metabolica, Italy

Aims: Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADIS) is a technically demanding hypo-absorptive bariatric procedure generally indicated in superobese and metabolic patients. Therefore, robotic platform could improve ergonomics against a thick abdominal wall, simplifying hand-sewn anastomosis and reducing the need for two-step procedures. Among 123 SADIS performed between June 2016 and November 2021, 23 were performed with the robotic platform (RA-SADIS). In this video we showed the standardization of the RA-SADIS.

Methods: A 50 years-old man with preoperative BMI 60.9 kg/m2, blood hypertension, type 2 diabetes mellitus and OSAS, underwent multidisciplinary care evaluation for TR-SADI-S.

Results: Patient lies in supine position with open legs. After 5 robotic trocars placement, a laparoscopic exploration was performed: the caecum, the last ileal loop and the ileal loop where anastomosis will be made (at 300 cm from ileocecal valve) are identified. The selected loop is then inked and anchored to the omentum, with a Vicryl 3.0 stitch. At this point robotic docking is performed, and all the procedure's steps were robotic-assisted. Procedure begins with the dissection of the gastrocolic ligament and proceeds with the preparation of the greater curvature, which is carried out cranially until the left diaphragm pillar is exposed and caudally to the pylorus. Then preparation of the first part of the duodenum is performed, until gastroduodenal artery is exposed. The next step is the vertical gastric resection, which is performed using a robotic stapler and sized upon a 40 F orogastric bougie. At this point the first part of the duodenum is sectioned with a robotic stapler, approximately 2 cm after the pylorus. Then, a double layer manual termino-lateral antecolic duodenal-ileal anastomosis between the sectioned proximal duodenum and the previously identified ileal loop is made, using PDS 3.0 for the external anterior layer and Stratafix 2.0 for the external posterior and the internal layer. The integrity of the anastomosis is verified. The operative time was 140 min (5 for docking step). Postoperative course was uneventful.

Conclusions: The robotic platform may represent an added value in the most challenging cases, safely increasing the rate of single step procedure.

ROBOTICS & NEW TECHNIQUES—Bariatrics

V054—Laparoscopic ligamentum Teres cardiopexy and hiatal hernia repair as an alternative for gastroesophageal reflux disease in a patient with a previous sleeve gastrectomy

Arturo Cirera de Tudela ¹ , R. Vilallonga², A. García Ruiz de Gordejuela², E. Caubet², O. González², M. Moratal¹, D. Herms¹, M. Comas³, A. Ciudin³, M. Armengol¹

¹Vall d'Hebron University Hospital, Department of General and Digestive Surgery. Universitat Autònoma de Barcelona, Spain, ²Vall d'Hebron University Hospital, Endocrine, Bariatric and Metabolic Surgery Unit. Department of General and Digestive Surgery, Spain, ³Vall d'Hebron University Hospital, Department of Endocrinology and Nutrition, Spain

Background: Although laparoscopic sleeve gastrectomy is the most frequent performed bariatric surgery procedure, there have been reports of increased severity and prevalence of gastroesophageal reflux disease (GERD). Many options have been considered to treat reflux after sleeve gastrectomy, including conversion to a Roux-en-Y gastric bypass, hiatal hernia repair, conversion or the placement of LINX® magnetic sphincter. Another surgical option includes cardiopexy using the ligamentum teres to achieve near-complete restoration of esophagogastric function and rehabilitation of damage caused by sleeve gastrectomy and hiatal hernia.

Clinical case: A 47-year-old woman with an initial weight of 141 kg and a BMI of 47.26 kg/m²was proposed for a laparoscopic Roux-en-Y gastric bypass in November 2017. Postoperatively, she presented a BMI of 24.2 kg/m². Two years later, the patient suffered from severe hypoglycemia, so a conversion to normal anatomy including a sleeve gastrectomy was done in May 2020. Thus, postoperatively, she had experienced severe GERD and regurgitation and did not respond to medical treatment. After the acceptance of the Research Committee and explaining the options to the patient, she was proposed for a laparoscopic hiatoplasty with a ligamentum Teres cardiopexy in November 2021. The procedure begins with the release of adhesions in the lesser curvature of the stomach. The dissection of the abdominal esophagus is continued until its complete release. The diaphragmatic crus are then closed with non-absorbable sutures. Finally, the round ligament is dissected and the cardipexy attached to the anterior crus is completed. The duration of the surgery was 50 min, and there were no intra- or early postoperative complications, so the patient was discharged on the second day after surgery. Two months after surgery, the patient achieved a resolution of GERD symptoms without proton pump inhibitors use.

Conclusions: Ligamentum teres cardiopexy combined with closure of the diaphragmatic crus or hiatoplasty is a feasible alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia.

ROBOTICS & NEW TECHNIQUES—Colorectal

V055—Giant Chordoma occupying the narrow pelvis of a male patient treated by an en-bloc Robot-Assisted Sacrectomy

L. Morelli, Cristina Carpenito, S. Guadagni, C. Gianfaldoni, G. Di Franco, M. Palmeri, N. Furbetta, A. Comandatore, C. Carpenito, L. Andreani, G. Di Candio, R. Capanna

¹University of Pisa, General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, Pisa, Italy

Aims: Given that surgery is the standard treatment of sacral chordoma, and considering its demanding nature particularly if developed in male patients and in strict contact with the rectum, we show a combined en-bloc sacrectomy aided by the robotic trans-abdominal approach.

Methods: A diagnosis of a sacral chordoma was accomplished in a 56 years old patient who presented with heavy back pain, costiveness, sub-occlusive episodes and neurological disorders. CT scan showed the anteriorization of the rectum by a bulky sacral chordoma extensively occupying the pelvis.

The procedure can be divided into two phases. In the abdominal phase the patient was placed in supine position with 30° Trendelenburg angle. The robotic trocars were placed in an oblique fashion, as we usually do for rectal resections. After docking of the da Vinci Xi platform, the operation started with the opening of the pelvic peritoneum at the level of the sacral promontory. Then we proceeded with the identification and dissection of the giant chordoma from the rectal wall anteriorly. The dissection was kept downwards into the deep pelvis till the elevator ani. The orthopedic phase was carried out in a prone position with hips abducted and gently flexed, knees flexed. Incision and isolation of the posterior aspect of the sacrum was done maintaining a wide resection margin. Sacrectomy was performed subsequent in a safe manner due to the previous rectal isolation. Finally, the wound was directly closed.

Results: The operation lasted 420 min. The tumor was completely removed without intra or post-operative complications. Neither the rectal wall, nor any other pelvic structure was damaged. No intestinal resections were needed. Post-operative course was uneventful. The pathology confirmed the diagnosis of malignant chordoma.

Conclusions: Sacral chordoma, due to its location and biological characteristics, may be very difficult to operate in a safe and oncologically correct way, especially for high volume tumor and in male patients with narrow pelvis. The possibility of exploiting the technical characteristics of the robotic platform (i.e., 3D vision, 7 degrees of freedom) allows a fine dissection from surrounding tissues in a minimally invasive fashion making the orthopedic phase easier and safer.

ROBOTICS & NEW TECHNIQUES—Flexible surgery

V056—Advantages of CMR Versius Robot for Anti-reflux Surgery

Matthew Doe ¹ , S. Hornby², S. Higgs², M. Vipond²

¹Gloucester Royal Hospital, Upper Gastrointestinal Surgery, United Kingdom, ²Gloucester Royal Hospital, Upper GI Surgery, United Kingdom

Aims. To illustrate the advantages of robotic assisted techniques for anti-reflux surgery, in particular the use of the CMR Versius modular system.

Methods. Gloucester Royal Hospital is the first UK trust to utilise the CMR Versius system for upper gastrointestinal surgery. Three consultant surgeons at have performed robotically assisted anti-reflux surgery over the past 6 months. Several key technical advantages have been identified and documented using one case in video format.

Results and Conclusions. The CMR Versius modular system provides separate arms improving versatility and reducing clashing intraoperatively. The 3D 4 K magnified view, combined with a steady laparoscope operated by the surgeon and wrist action of the robotic arms, combine to provide enhanced precision with intracorporeal suturing and oesophageal mobilization especially.

Unique to upper GI surgery is the ability to perform a top-down fundal mobilization and short gastric division. Finally the open surgeon’s console has human factors advantages as the surgeon is able to see and communicate easily with the scrub and anaesthetic team whilst operating.

HEPATO-BILIAIRY & PANCREAS—Liver

V060—Laparoscopic left hemihepatectomy with division of each portal triad using ICG cholangiography

Jun Muto, S. Nomura, K. Hashida, H. Kitagawa, K. Kawamoto

¹Kurashiki Central Hospital, Department of General Surgery, Japan

Background: Laparoscopic hepatectomy is now widely performed, however open laparotomy is still frequently chosen on biliary system disease. Because deciding dissection line of bile duct is difficult in laparoscopic hepatectomy. Indocyanine green (ICG) fluorescence is used on evaluation of demarcation line and cholangiography in hepatectomy, however there is no report using ICG cholangiography to determine dissection line of bile duct in laparoscopic hepatectomy. We are reporting laparoscopic left hemihepatectomy with division of each portal triad using ICG cholangiography.

Materials and Methods: Endoscopic nasobiliary drainage (ENBD) tube was placed on the day before surgery. Laparoscopic hepatectomy was performed with 6 trocars including trocar for Pringle’s maneuver. After mobilization of left lobe, a tourniquet system was set on hepatoduodenal ligament for Pringle’s maneuver. Left branch of Glissonean pedicle was encircled and taped, and arteries and portal vein are divided and dissected. Left hepatic duct is isolated and observed with ICG cholangiography via ENBD tube. Left hepatic duct was dissected and stump was examined on intraoperative tissue diagnosis. ICG was injected intra venously, demarcation line was observed. Liver parenchyma was dissected and left hepatic vein was dissected with autosuture device.

Discussion: With ICG cholangiogaphy, bile duct can be observed during isolation. Additional resection is available incase positive bile duct margin. Glissonean pedicle of caudate lobe from left branch can be easily approached with traction of left branch stump.

Conclusion: ICG cholangiography was useful to determine dissection line of bile duct in laparoscopic left hemihepatectomy with division of each portal triad.

HEPATO-BILIAIRY & PANCREAS—Liver

V061—Laparoscopic right hemihepatectomy with vena cava suturing

Wojciech Serednicki, M. Wierdak, J. Rymarowicz, A. Rzepa, M. Matyja, M. Pędziwiatr

¹University Hospital in Cracow, IInd Department of General Surgery, Poland

Laparoscopic liver resection has devoloped significantly in recent years becoming a standard procedure in many medical centers. In experienced hands, laparoscopic right hemihepatectomies are associated with reduced hospital stay and blood loss, but are associated with higher intraoperative complication risk.

We present a case of a 36 year old man with a large liver tumor in segments 6 and 7 compressing right hepatic vein. In preoperative MRI there was a high suggestion of FNH (Focal nodular hyperplasia) or adenoma and rapid tumor enlargement from 60 to 130 mm within the last year. Patient was symptomatic with abdominal discomfort and had abnormal liver function tests. He was scheduled for laparoscopic right hemihepatectomy. Procedure was performed using 5 trocars, 3 of them in right subcostal area. After that falciform ligament was released and right hepatic artery (RHA) and right portal vein (RPV) was dissected and clamped temporarly to confirm resection margins. Then RHA and tight branch of RPV was clipped and cut off. Subsequently the liver was mobilized with a small hole in the diaphragm occuring, which was sutured. Although RPV was clipped using a hemolock, a bleeding beneath it occured, showing a hole in vena cava, which was the sutured providing proper hemostasis. After that the resection line was set and Pringle Manouver has started. Transection was performed using ultrasonic scalpel, clips and staplers to seal the large vessels. Tumor was removed in endobag via minilaparotomy due to its size. Hemostatic powder was used on the liver surface to avoid postoperative bleeding. The round ligament was attached to abdominal wall to stabilize the liver remnant. There were no postoperative complications and the patient was discharged on the 7th postoperative day. Histopathological examination confirmed the previos FNH suspicion.

HEPATO-BILIAIRY & PANCREAS—Liver

V062—Laparoscopic right hemihepatectomy is feasible for intrahepatic cholangiocarcinoma proximal to the right posterior Glisson’s pedicle

Kazuki Hashida, J. Muto, S. Nomura, H. Kitagawa, K. Kawamoto

¹Kurashiki Central Hospital, General Surgery, Japan

Background; laparoscopic hemihepatectomy is challenging for intrahepatic cholangiocarcinoma (ICC) proximal to the right posterior Glisson’s pedicle.

Aim: Laparoscopic right hemihepatectomy was successfully performed for ICC proximal to the right posterior Glisson. We report the surgical procedures.

Surgical procedure: The patient was placed in a left hemi-decubitus position. The right lobe was completely mobilized and the inferior right hepatic vein was cut by a stapler. The intraoperative diagnosis of lymph node biopsies in the hepatoduodenal ligament was no metastasis. The right hepatic artery was ligated and cut, and the pedicles of the right anterior and posterior portal branch were ligated and dissected. During transection of the hepatic parenchyma we used the intermittent vascular occlusion. The caudate lobe in front of the IVC was dissected firstly. The hepatic transection around the hilar plate was performed. When the hilar plate was exposed clearly, the right hepatic duct was dissected by the stapler using the intraoperative ICG imaging of the bile duct. Hepatic transection was performed from the IVC to the demarcation line of the liver surface. Finally the pedicle of the right hepatic vein was dissected by the stapler. After the negative margin of the right hepatic duct was checked intraoperatively, the surgery was finished.

Result: Operation time was 534 min and the intraoperative blood loss was 20 ml. The patient was discharged without complications after eight days.

Conclusion: Laparoscopic hemihepatectomy was feasible for mass-forming intrahepatic cholangiocarcinoma proximal to the pedicle of the Glisson.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V063—Totally Laparoscopic Management of Gallstone Ileus

Jason George, A. Harris

¹Hinchingbrooke Hospital, Department of Upper GI Surgery, United Kingdom.

Aims: Gallstone ileus is a rare complication of cholelithiasis. Typically, it occurs in elderly patients with multiple comorbidities. The mainstay of treatment has been laparotomy plus enterotomy and stone extraction to relieve the obstruction. Since the 1990s, there have been several reports of laparoscopic management. However, many reports actually describe laparoscopic-assisted enterolithotomy. This video demonstrates the successful treatment of gallstone ileus using a totally laparoscopic approach.

Methods: A 77 year old female presented with features of small bowel obstruction. Past medical history included hypertension and type 2 diabetes. She had been admitted a few weeks previously and diagnosed with a cholecystoduodenal fistula. On the second admission she was initially treated with nasogastric tube decompression and intravenous fluids. CT scan (Fig. 1) demonstrated Rigler’s triad of pneumobilia, small bowel dilatation and an aberrant large gallstone in the distal ileum, consistent with gallstone ileus.

Results: This video demonstrates laparoscopic enterotomy and stone extraction. A 5 cm gallstone (Fig. 2) was retrieved through a longitudinal enterotomy. Intracorporeal suturing was performed to close the enterotomy. The patient made a good recovery and was discharged home after three days.

Conclusions: In selected cases, total laparoscopic management of gallstone ileus is a valid option. It should be performed only by surgeons with appropriate laparoscopic skills and expertise. This approach has obvious benefits for elderly patients in terms of morbidity and recovery.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V064—Laparoscopic Cholecystectomy for Cholecystocutaneous Fistula in a patient with Type 2 Diabetes and Guillain-Barré Syndrome

Panagiotis Kapsampelis, I. Shah, M. Gaber, I. Gerogiannis

¹Kingston Hospital NHS Foundation Trust, Department of Surgery, United Kingdom

Introduction/Aims: Cholecystocutaneous fistula is an abnormal communication of the gallbladder and the skin caused by cholelithiasis or cholecystitis. This complication is rarely seen today because of early diagnosis and management of gallbladder disease. However, patients with certain comorbidities are more susceptible to developing this complication.

We present a video of cholecystocutaneous fistula managed laparoscopically.

Methods/Technique: A 70-year old male with chronic calculous cholecystitis, Guillain-Barré syndrome and type 2 diabetes mellitus presented to the Upper Gastrointestinal Surgical Clinic after GP referral. He suffered from chronic abdominal pain and leak from the fistula.

The first port was placed using the Hasson technique. Upon entrance to the abdomen, extensive peritoneal adhesions were encountered. The remaining ports were placed under vision, in the best possible ergonomic position and according to intraoperative findings. Adhesiolysis was performed with scissors and diathermy. The gallbladder was covered with omentum resulting in a mass, which adhered to the anterior abdominal wall, and contained the gallbladder, right lobe of the liver and omentum. The gallbladder was separated from the omentum with careful dissection. After attempting to release the gallbladder from the abdominal wall, a cavity containing multiple stones was revealed. The fistula tract extended from the gallbladder to the dermal opening. Numerous stones were extracted from the abdominal wall and the gallbladder opening. A large stone (4 cm), lodged in Hartmann’s pouch, was removed. Due to plastering of the Calot triangle area close to the duodenum, we proceeded to subtotal cholecystectomy for safety. A small part of the infundibulum was left. The free gallbladder edges were closed with a continuous layer of 2–0 Ethibond™ sutures below and an interrupted layer above. More suturing was avoided due to gallbladder wall necrosis.

Results: The postoperative course was uneventful, and the patient was discharged on the 2nd postoperative day. He subsequently underwent ERCP as an outpatient.

Discussion: Cholecystocutaneous fistula is rare nowadays due to early diagnosis and treatment of gallstone disease. When it develops, cholecystectomy is the preferred treatment. The laparoscopic approach is possible but requires advanced laparoscopic skills and has a conversion rate to open that is high but acceptable.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V065—Laparoscopic management in residual gallbladder and cystic duct stump stone after cholecystectomy

Razvan Popescu, N. Leopa, C. Olteanu, F. Ciobanu

¹Emergency Country Hospital of Constanta/ Ovidius University of Constanta, General Surgery, Romania

Introduction: Post-cholecystectomy syndrome (PCS) occurs in 10–40% of patients anywhere between 2 days and 25 years, due to biliary and nonbiliary causes. Remnant gallbladder or cystic duct stump is a common biliary cause with a challenging and difficult diagnosis. Symptomatic patients with cystic duct stones after cholecystectomy require surgery. We will present a case-series of laparoscopically solving gallbladder and cystic duct stump stone after cholecystectomy.

Material and Method: We present the case of three patients who were treated as having residual gallbladder stone/cystic duct stump stone by using completion cholecystectomy using laparoscopic technique. Symptoms at presentation were recurrent biliary colic, followed by dyspepsia, cholangitis and fever. The diagnoses of all cases were carried out by using abdominal ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP).

Results: Laparoscopic completion cholecystectomy was completed successfully in all cases. ERCP and papillotomy were carried out before completion of cholecystectomy in 2 cases and CBD was cleared in all cases. Regarding the initial surgery, 2 patients had open cholecystectomies and 1 patient had laparoscopic cholecystectomy, performed for acute cholecystitis. The interval since the initial operation was 6–11-14 years. In all cases there were adhesions between the liver and the colon/duodenum/great omentum, to a greater degree after open surgery. Subtotal cholecystectomies were diagnosed in 2 cases, and one patient had a cystic duct remnant. The duration of hospitalization after surgery was 3 days. All patients were asymptomatic at 6 months’ follow-up.

Conclusions: Residual gallbladder or cystic duct stump stone is a preventable and correctable cause of PCS. symptomatic patients with remnant cystic duct stump stone/subtotal cholecystectomy that require surgery are difficult to manage Laparoscopic surgery is preferred for the benefits that laparoscopic surgery brings, but requires trained and experienced teams in laparoscopic surgery.

HEPATO-BILIAIRY & PANCREAS—Liver

V066—Primary or Iterative Robotic Liver Resection for Lesion Located in Seg VII

C. Cutolo, Andrea Belli, R. Patrone, M. Leongito, C. Cutolo, G. Pasta, V. Granata, F. Izzo

¹National Cancer Centre-G.Pascale, Hepatobiliary Surgery, Italy

Aims: the aim of this video is to demonstrate the feasibility of robotic apprroach to posterior liver segments, also for redo surgery.

Methods: we show two clinical case of lesion located in seg VII. The first clinical case was a metastasis from colorectal cancer in a patient previously submitted to left emicolectomy. The second one was a case of redosurgery, in a patient previously submitted to left emicolectomy + atypical liver resection of seg iv and vii, with a new metastasis at VII seg.

Conclusions: robotic liver approch is also feasibe in redo surgery.

HEPATO-BILIAIRY & PANCREAS—Liver

V067—Thoracoscopic liver resection for lesion located in segment 7

Wojciech Serednicki, A. Rzepa, M. Wierdak, M. Pędziwiatr

¹University Hospital in Cracow, IInd Department of General Surgery, Poland

Laparoscopic liver resection, introduced in early 1990s has improved due to technical innovations and accumulated surgeons experience. It is now a safe and effective procedure with fast postoperative recovery. However, in some cases, it may prove a great challenge. Especially with thee tumor location in the subdiaphragmatic ares of liver segments 7 and 8 and the patient medical history of previous abdominal surgeries the. Therefore novel techniques, such as thoracoscopic approach are being introduced. Hereby we present a case of thoracoscopic liver resection for lesion located in segment 7, performed for a second time in Poland.

We present a case of a 54 years old woman, a COVID survivor, with BMI 33 kg/m2 with a liver lesion in segment 7, which was highly suggestive of metastasis. She was 12 months after laparoscopic sigmoid resection (T3N1c) and adjuvant chemotherapy. She has a history of three previous abdominal surgeries. CT showed a 17 mm lesion in 7th liver segment in posterior location. After preoperative counselling, due to the inconvenient location of the tumor and previous abdominal surgeries, the patient was scheduled for a thoracoscopic non-anatomical liver resection. Intraoperatively post-COVID adhesions were visible and adhesiolysis was performed. After dissecting the lung parenchyma and the diaphragm, location of the tumor was confirmed with the intraoperative ultrasound. After maintaining a good access the tumor via thoracoscopic approach, the lesion was dissected with the appropriate margin using the harmonic scalpel and removed in a endobag. After achieving hemostasis and suturing the diaphragm the lung was fully expanded and the procedure was finished with one chest tube left. Blood loss was 50 ml with no need of transfusion. There were no postoperative complications and the patient was discharged on postoperative day 3.

UPPER GI—Gastroduodenal diseases

V070—Laparoscopic Resection of GIST located in the third Duodenal Portion

Paula Domínguez-Garijo ¹ , S.T. Nogueira², F.B. Lacy², A.M. Lacy²

¹Hospital Clínic of Barcelona, General Surgery, Spain, ²Hospital Clínic of Barcelona, Gastrointestinal Surgery, Spain

Aim: Complete surgical resection is the only curative treatment for gastrointestinal stromal tumors (GIST). Duodenal involvement, with a relatively infrequent prevalence of 5% to 7%, constitutes the most complex site for the treatment of this neoplasm, depending on the location, size of the tumor, its anatomical relationships and the ability to achieve an R0 resection. The following video illustrates an example of local resection of duodenal GIST located in the third portion using a laparoscopic approach.

Methods. A 60-year-old woman with no pathological history was diagnosed of duodenal GIST in context of abdominal pain with anorexia and weight loss of 5 kg. Endoscopic ultrasound revealed a 20 × 16 mm submucosal tumor in the posteroinferior aspect of the third duodenal portion, which turned out to be a GIST positive for CD117 and DOG1 and negative for CD34, AML and S-100. Computerized tomography described the hypervascular lesion in contact with the inferior mesenteric artery on its posterior margin and with the jejunal venous trunk and duodenal arterial branches on its anterior margin. After evaluation in a multidisciplinary committee, it was proposed for surgical resection.

Result. A laparoscopic resection of the tumor was performed. During exploratory laparoscopy, the tumor was identified in the posteroinferior third portion of the duodenum, immediately proximal to the angle of Treitz. It had a slightly larger size than previous descriptions, and wedge resection with an endostapler was not possible. A duodenal enterotomy was performed, guaranteeing complete resection of the lesion, without requiring segmental duodenectomy.

The pathological results revealed a spindle cell GIST with a size of 2.3 cm and stage T2, with the same immunohistochemical pattern obtained previously in the biopsy. Surgical resection margins were negative.

The patient had an uneventful postoperative period, starting oral tolerance within the first 24 h after surgery and being discharged on the second day. She is currently disease free.

Conclusions: Laparoscopic approach for local resection of duodenal GIST is safe and feasible in selected small tumors, with excellent surgical and oncological results.

UPPER GI—Esophageal cancer

V072—Robotic Total Esophagectomy with Intrathoracic Circular Mechanical Anastomosis

Eugenia Butori, D. Momblan, C. González-Abós, P. Domínguez-Garijo, R. Curell, R. Pena, A.M. Lacy

¹Hospital Clinic de Barcelona, Gastrointestinal and General Surgery, Spain

Aims: Surgery is the cornerstone in the multimodal treatment of esophageal cancer. Esophagectomy is a highly complex procedure, associated with significant morbidity and mortality. Minimally invasive surgery has shown to be superior to open approach in terms of perioperative complications and in-hospital mortality. Robotic assisted surgery facilitates precise dissection and fine manipulation compared to laparoscopy.

In most robotic assisted esophagectomies linear mechanical or hand sewn anastomosis are performed. We present the case of a high intrathoracic circular mechanical esophagogastric anastomosis.

Methods: We present the case of a 66-year-old male patient with a squamous cell carcinoma of the middle third of the esophagus T3N2M0, who received neoadjuvant chemoradiotherapy and subsequently underwent a minimally invasive total esophagectomy. The procedure was performed through laparoscopy and robotic-assisted thoracoscopy.

The abdominal phase begins by releasing the greater gastric curvature, with preservation of the right gastroepiploic vascularization. Next, left gastric artery is sectioned and botulinum toxin is injected at the pylorus. Finally, a vertical gastroplasty is made with an endostapler.

For the thoracic phase, the patient is placed in left lateral semi-prone position and the Da Vinci Xi robot is docked. Caudal to cranial dissection of the esophagus is performed to obtain an en-bloc resection with the associated lymphatic tissue. The azygous vein is then sectioned using an endostapler. The proximal esophagus is sectioned using an endostapler and a circular mechanical anastomosis is performed. The anvil is introduced in the esophageal stump through the mouth attached to a orogastric tube and the circular stapler is placed in the gastric plasty through the enlargement of the assistant port. Finally, the mechanical end-to-side esophagogastric anastomosis is performed. The closure of the gastrotomy is performed using a linear endostapler, reinforced by PDS stitches and an epiploic patch.

Results: The postoperative period showed no complications and the patient was discharged in the 6th postoperative day.

Conclusions: Robotic approach provides greater maneuverability and facilitates surgery in reduced surgical fields, as in this case, adding value in pathologies in which postoperative complications involve significant morbimortality and influence long-term survival.

UPPER GI—Gastric cancer

V073—Robotic wedge gastrectomy for posterior wall gastric GIST

G. Bianchi¹, Nicola de'Angelis ¹ , F. M. Marchegiani¹, A. M. Madaro², N. dA. de'Angelis¹

¹Henri Mondor Hospital, AP-HP, Unit of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, France, ²Miulli Hospital, Acquaviva delle Fonti, Unit of Hepato-Pancreatic-Biliary Surgery, Italy

Aims: We present the case of a 58-year-old male patient (BMI: 23.1) diagnosed with a gastrointestinal stromal tumor (GIST) of the stomach. The preoperative evaluation showed a 4-cm GIST located in the gastric posterior wall with a KI67 index of 3%. After a multidisciplinary team discussion, a wedge gastrectomy was planned.

Methods: The patient was operated on with the da Vinci Xi Surgical System® (Intuitive Surgical, Sunnyvale, USA) with a single docking approach. The patient was placed in the supine reverse Trendelenburg position with the arms laid along the body. Four robotic trocars (3 of 8-mm, one of 12-mm) and one 5-mm laparoscopic trocar (AirSeal®, Conmed Corp, Utica, NY, USA) were used. The dissection was performed with monopolar curved scissors, fenestrated bipolar forceps, and the EndoWrist Vessel Sealer. The procedure started with the stomach mobilisation; the omentum was released and ligated from the greater gastric curvature with the energy-based device. The exposition of the gastric posterior wall permitted to reveal a gastric GIST highly adherent to the retroperitoneum, the pancreatic capsule, and the splenic artery. A precise and careful dissection to release the gastric GIST from the retroperitoneal organs and vessels was required. Once the lesion and the stomach were completely mobilized, a wedge gastrectomy was performed with 2 green recharges of the 60-mm SureForm® robotic stapler. A 3–0 barbed monofilament running suture was applied on the stapler line to ensure adequate hemostasis. The surgical specimen was extracted with a 3-cm incision in the place of the 12-mm robotic port.

Results: The overall operating time was 160 min. The postoperative period was uneventful, and the patient was discharged at POD 5 The pathology report showed an R0 gastric resection of a 5-cm gastric GIST with a mitotic index > 5/50 HPF and a KI67 index of 4% (intermediate risk lesion according to Joensuu criteria).

Conclusion: With its seven degrees of freedom, tremor filtering, and motion scaling, the robotic technology may contribute to improve precision in procedures requiring highly accurate dissection.

UPPER GI—Reflux-Achalasia

V074—Laparoscopic re-do fundoplication for progressive dysphagia—conversion from Nissen to Toupet

Adrian Harris

¹Hinchingbrooke Hospital, General Surgery, United Kingdom

Aims: Re-do fundoplication is usually performed for recurrent reflux symptoms due to wrap failure or recurrent hiatus hernia. Conversely, persistent dysphagia may occur early due to tight wrap or crural repair, which should be avoided by good surgical technique. A small group of patients however may suffer progressive dysphagia due to weakening oesophageal motility (especially in older patients), fibrosis of the wrap or a combination of the two. This video demonstrates the successful treatment of this problem with a laparoscopic conversion from Nissen to posterior Toupet fundoplication.

Methods: A 72 year old man underwent an uncomplicated laparoscopic Nissen fundoplication in 2015 with complete resolution of reflux symptoms. He re-presented 2 years later, still free of reflux but suffering progressive dysphagia and troublesome regurgitation. Investigations demonstrated intact wrap, no mechanical obstruction and no recurrence of hiatus hernia, but did confirm low-amplitude peristalsis. Prokinetics did not help but a trial of endoscopic dilatation improved symptoms for 11 days before recurrence of dysphagia, suggesting likely wrap fibrosis (which would reduce elasticity and impede passage of food bolus), justifying consideration for a conversion from Nissen to Toupet.

Results: This video demonstrates the expected adhesions between fundoplication and inferior surface of left lobe liver, mobilisation and division of the Nissen fundoplication, and reconstitution of a posterior Toupet fundoplication. The patient made a good recovery and was discharged the following day. Follow-up to 1 year confirmed complete resolution of symptoms with no recurrence of reflux.

Conclusion: Laparoscopic re-do surgery for late-onset progressive dysphagia is a safe and viable option. Patients must be thoroughly investigated and carefully selected for an appropriately-tailored procedure. They should also be advised of the increased risks associated with re-do surgery. The anatomy can be unpredictably distorted by variable adhesions and this operation should therefore only be performed by laparoscopic surgeons experienced in both primary and re-do fundoplication.

UPPER GI—Benign Esophageal disorders

V076—Robot-assisted enucleation of esophageal supracarinal leiomyoma

Andrea Pansa, G.M. Garbarino, M.I. Van Berge Henegouwen, S. Gisbertz

¹Amsterdam UMC, Department of Surgery, The Netherlands

Aims: the aim of this video is to show a robotic-assisted enucleation of a leiomyoma of the upper third of the esophagus.

Methods: the patient was placed in a semi-prone position, four robotic and one assistant trocars were used. Intraoperative endoscopy was performed prior to incision to precisely localize the tumor. Double-lung ventilation was performed, CO2 pneumothorax was set at 6 mmHg.

Results: the leiomyoma was enucleated without damaging the capsule. Total operative time was 120 min. No intraoperative complications occurred. The mucosal layer was intact at the end of the procedure. The muscular layer and the pleura were sutured separately with 4–0 v-lock stitches. A chest drain and a nasogastric tube were left for one night. Postoperative course was uneventful, the patient was discharged on postoperative day 2 on a semi-solid diet.

Conclusion: robotic enucleation of a supra-carinal esophageal leiomyoma was performed. The advantages of the 3D magnified view and the wrist-like movement of the instruments allowed a safe and precise dissection and anatomical reconstruction even at the thoracic inlet.

COLORECTAL—Benign

V077—Laparoscopic approach for the treatment of a retrorectal tumor

Ivette Tort, H. Galán, C. Pilar, A. Sánchez, J.C. Pernas, S. Fernández-Ananín, E. Targarona

¹Hospital de la Santa Crue i de Sant Pau, Department of General and Digestive Surgery. Unit of Gastrointestinal and Hematological Surgery, Spain

Aims: Retrorectal tumors are an extremely rare type of tumors that can arrise from a very diverse range of histological origins. The indicated treatment is surgical excision to avoid complications and to rule out malignancy. It was classically done by a perineal approach or by a laparotomy technique, depending on the tumor characteristics. But current, medical literature shows really good outcomes with a laparoscopic approach, as we would like to show in this video presentation.

Methods: This is a clinical case about a 41-year-old female without any medical conditions except for repeated history of renal colic. When this condition was being studied, an asyntomatic retrorectal tumor was found incidentally in a CT-SCAN. The radiological images showed a presacral tumor located above the rectum and intimately related to it, which went from the sacral vertebrae 2 to 5. Its radiological features were compatible with soft tissue, of 4.7 and 4.9 cm in an axial plane. The pelvic MRI suggested a neurogenic tumor, probably a schwannoma. The study was completed with a colonoscopy, which didn’t found any abnormalities in the rectum. The proposed treatment was a laparoscopic approach aiming a complete excision of the tumor.

Results: The surgery was performed without complications. The tumor, which was identified near to the pelvic floor and just behind the rectum, was dissected in its entirely by blunt dissection, avoiding accidental opening. After the surgery, the patient made an uneventful recovery and the final pathologic diagnosis was confirmed to be a schwannoma. In the follow-up period, no clinical or radiological findings of recurrence have been found, no complications of the surgery have been identified. The patient remains asymptomatic.

Conclusion: A laparoscopic approach is feasible and safe for retrorectal tumors when performed by experienced surgeons. When comparing to opens surgery, laparoscopic approach has similar mean operating time, shorter hospital length stay and similar intra-operative and post-operative complications. Furthermore, it enhances visualization of pelvic structures and facilitates precise dissection of the tumor from adjacent structures. That’s why it should be always considered and can be performed in appropriate cases."

COLORECTAL—Malignant

V078—Laparoscopic Complete Mesocolic Excision (CME) with vascular anatomy: step-by-step approach with digitally enhanced anatomy

Lorenzo Bernardi, A. Cristaudi, R. Roesel, D. Christoforidis, S.G. Popeskou

¹Ospedale Regionale di Lugano, Department of Surgery, Switzerland

Background: Right hemicolectomy (RH) according to the principles of complete mesocolic excision (CME) provides specimens of superior oncological quality compared to the traditional hemicolectomy with a benefit on survival for advanced cancer stages. However, due to the technical requirements and possibility of serious complications the technique is not yet the gold standard.

Methods: We present a step-by-step approach for a safe and effective laparoscopic RH with CME.

Procedure: Retracting latero-caudally the ileo-cecal junction, the cecum and the root of the ileocolic vessels are identified. The peritoneum is opened below the confluence of the ileocolic vein (ICV) into the superior mesenteric vein (SMV) which presents usually as a V shaped configuration (the V-view, as described by Strey, et al.). Then the dissection is carried through the avascular plane between the intact mesocolic fascia (ileocolic page) and the retroperitoneum (retroperitoneal page) until the Lesser sac is opened and the pre-pyloric region, the duodenum (II pars) and the head of the pancreas are visualized.

The confluence of the ICV is dissected free and sectioned between hem-o’-Loks. The ileocolic artery (ICA) shows up running behind the ICV in this case, its origin from the superior mesenteric artery (SMA) is dissected and sectioned at the right border of the SMV.

The dissection continues cephalad along the SMV. This patience presents both right colic vein (RCV) and artery (RCA) which are dissected and sectioned at the confluence of into the SMV and at the origin from the SMA respectively.

More cephalad the Henle’s trunk (HT) anatomy is identified consisting in a tripod of pancreatic branches (two), gastro-epiploic vein (GEV), right superior colic vein (RSCV). Before managing the HT, the middle colic artery (MCA) is identified opening the mesocolon anterior to the SMV. The MCA is dissected free proximally until its origin from the SMA and caudally to identify its right and left branches: the right branch is taken. The RSCV can be now sectioned at its confluence into the HT, while other branches of the HT are carefully preserved.

Conclusion: A safe and oncologically sound laparoscopic CME.

COLORECTAL—Malignant

V079—Anterior resection with en bloc hysterectomy for rectal cancer completed laparoscopically with vaginal extraction

K. Campbell¹, Angelos Pazidis ¹ , D. Kumar², K. Ragupathy³

¹Ninewells Hospital & Medical School, Colorectal Surgery, United Kingdom, ²Ninewells Hospital & Medical School, General surgery, United Kingdom, ³Ninewells Hospital & Medical School, Gynaecology, United Kingdom

A joint procedure between gynaecological and colorectal surgeons to resect an upper rectal cancer in which the posterior wall of the uterus could not be separated from the anterior rectal wall, is shown. An en bloc resection was completed laparoscopically with the aid of a uterine manipulator to guide division of the vaginal vault and use of a condom inflated through a foley catheter to prevent loss of pneumoperitoneum. Following division of the vaginal vault rectal dissection and division could be completed. The combined specimen was retrieved through the vaginal vault which was repaired laparoscopically prior to completing a stapled colorectal anastomosis. Recovery was uneventful with discharge home day 4. Combining the techniques of laparoscopic hysterectomy and rectal resection extends the range of minimal access techniques in rectal cancer while allowing natural orifice extraction.

The findings in the Pouch of Douglas were unexpected as the MRI scan had shown a T3 cancer with a clear circumferential resection margin. There were cystic lesions noted in the pelvic peritoneum extending laterally but frozen section was benign and excluded peritoneal spread. In this case access to complete an adequate mesorectal dissection and form an anastomosis in healthy tissue was not possible without hysterectomy. Final pathology confirmed an R0 resection, T3N0M0 but revealed the unexpected finding of endometriosis involving the Pouch of Douglas rather than advanced cancer.

There is very little literature on endometriosis with colorectal cancer. In the largest series reported Ishii et al. conclude that “intestinal endometriosis with colorectal cancer is a relatively rare disease and is difficult to distinguish from T4 cancer”.

Intestinal endometriosis combined with colorectal cancer: a case series. Ishii M, Yamamoto M, Tanaka K, Asakuma M, Masubuchi S, Hamamoto H, Akutagawa H, Egashira Y, Hirose Y, Okuda J, Uchiyama K. J Med Case Rep. 2018 Jan 30;12(1):21.

COLORECTAL—Benign

V080—Minimally invasive perineal redo surgery for rectovesical and rectovaginal fistulae: A case series

Alexander Grüter

¹Amsterdam UMC, Department of Surgery, The Netherlands.

"Introduction: Iatrogenic recto-urogenital fistulae are refractory complications that rarely heal without surgical intervention. The ongoing local infection causes pain, discomfort and substantially impacts quality of life. Surgical repair requires adequate exposure and space to fill with healthy tissue, which is a major challenge in pelvic redo surgery. An abdominal approach to repair the fistula is associated with major morbidity and often fails to expose the deep pelvis. In our experience a novel transperineal minimally invasive approach a utilizing single incision laparoscopic surgery (SILS) technique could offer improved results.

Presentation of cases: In the present study, three cases of patients with recto-urogenital fistulae after pelvic surgery are described. Two patients were diagnosed with a rectovesical fistula and one patient with a rectovaginal fistula. In all three cases, a minimally invasive perineal approach, using a SILS port, was used to perform surgical repair. The closure of the fistulae involved: a separate repair of the urethra/bladder or vaginal defect and the rectal defect, followed by interposition of vascularized tissue by either a pudendal thigh fasciocutaneous flap or omentoplasty.

Discussion and Conclusion: This study is the first to report on a minimally invasive perineal approach, utilizing a SILS technique for recto-urogenital fistulae repair after previous pelvic surgery. The current approach improves exposure, creates surgical space, optimizes view and allows the interposition of vascularized tissue, without causing substantial blood loss and avoiding major abdominal surgery."

COLORECTAL—Benign

V083—Laparoscopic appendicectomy: step by step with alternative approaches and evidence summary

S. Sharma, Kenneth Campbell, K. Campbell, P. Patil

¹Ninewells Hospital, General Surgery, United Kingdom

Laparoscopic appendectomy (LA) is the recommended treatment for acute appendicitis and is superior to open appendicectomy in terms of wound infection, post-intervention morbidity, hospital stay, and quality of life scores [1].

Appendicectomy is one of the most frequent emergency surgical procedures. As a result, in most surgical curricula LA is labelled as an index procedure and General Surgical trainees are expected to achieve a level-3 competency (procedure performed with minimal or no guidance) in the early phase of specialty training.

Because LA is performed as an emergency, trainees, inevitably operate with different trainers (consultant and senior trainees) and can lack a sense of standardisation of the operative technique and choice of instruments. In addition, acute appendicitis presents a variety of challenges requiring a range of techniques to be in the armamentarium of the surgeon.

In this video montage using operations performed by trainees at various stages in training we go through the procedure according to the following steps:

induction of safe pneumoperitoneum, port placement, diagnosis, dissection of the mesoappendix, identification of the appendico-caecal junction using critical view of safety [2], ligation of appendicular stump and retrieval. The different possible approaches and published evidence has been reviewed and summarised at each step.

Appreciation of the variety of approaches possible in LA is a potentially useful resource for surgeons in training seeking to expand their repertoire in laparoscopic techniques.

Bibliography:

Di Saverio, S. et al. (2020) ‘Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines’, World Journal of Emergency Surgery. BioMed Central Ltd. doi: 10.1186/s13017-020-00306-3.

Subramanian, A. and Liang, M. K. (2012) ‘A 60-year literature review of stump appendicitis: the need for a critical view’, American journal of surgery, 203(4), pp. 503–507. doi: 10.1016/J.AMJSURG.2011.04.009."

COLORECTAL – Malignant

V084 - Laparoscopic extended left hemicolectomy for transverse colon cancer with S4 liver resection for synchronous metastasis guided by NIR ICG Fluorescence

Silvia Quaresima ¹ , Q. Lai¹, V. Pappalardo¹, G. La Barba², S. Colombo³, Z. Lauriero¹, G. Nigri⁴, A. Paganini¹, M. Rossi², S. Di Saverio⁵

¹Sapienza University of Rome, Department of General and Transplant Surgery “Paride Stefanini”, Italy, ²Ospedale Morgagni Pietrantoni, AUSL Romagna, Italy, ³Istituto Europeo Oncologico, General Surgery, Italy, ⁴University of Rome Sapienza, San'Andrea University Hospital, Italy, ⁵Sapienza University of Rome; ASUR Marche, Department of General and Transplant Surgery “Paride Stefanini” ; San Benedetto del Tronto Hospital, Italy

We present the case of a 68 year old gentleman affected by transverse colon carcinoma with synchronous IV hepatic segment metastasis . CT scan and MRI showed a locally advanced colon cancer with multiple lymphoadenopathy and a nodule of 1,6 cm in diameter sited at the IV liver segment suspected for synchronous metastatic lesion. A videolaparoscopic extend right hemicolectomy with complete mesocolic excision (CME) e central vein ligation (CVL) associated to IV segment resection guided by Indocianine green (ICG) Near Infrared Fluorescence (NIR) was planned. Patient one week before surgery undergone intravenous administration of 0,1 mg x KG of ICG. First surgical step of minimally invasive procedure was the liver segmentectomy guided by intraoperative laparoscopic ultrasound scanner and ICG fluorescence, the procedure was completed by performing the extended right hemicolectomy according to CME and CVL criteria. Service laparotomy in right flank, protected by extractor was performed and a mechanical side-to-side ileo-colic anastomosis was carried out. No intraoperative complications were observed. Patient was discharged after 10 days of uneventfull hospital stay. Definitive pathology showed R0 colic and liver resection margins, final stage was T4 N1 (2/36) M1. Patient undergone adjuvant therapy and is disease free at 10 months follow-up.

COLORECTAL – Malignant

V085 - Robotic Abdominoperineal Resection and excision of Ileoanal Pouch for a recurrent cancer on the anorectal stump in a patient with ulcerative colitis

M. Youssif, Ali Toffaha, A. Parvaiz, A. Ahmed, M. Abunada, A. Toffaha

¹Hamad Medical Corporation, Colorectal Surgery, Qatar

54 year old gentleman a known case of Ulcerative Colitis since 2009. Surveillance colonoscopy showed a low rectal lesion 4 cm from the anal verge (figure 1). Biopsy revealed high grade dysplasia. he underwent Laparoscopic proctocolectomy with ileal pouch anal anastomosis. The histopathology of the resected specimen at the time showed no malignancy and benign lymph nodes (0/19).

Three months later patient had burning anal pain and diarrhoea for which he underwent sigmoidoscopy that showed severe ulceration at the pouch outlet (figure 2). Biopsy showed high grade dysplasia.

The patient underwent transanal mucosectomy on the remnant rectal mucosa with a histopathology of (pTispNx)

Following the procedure, the patient had another sigmoidoscopy and biopsy that showed invasive adenocarcinoma.

His case was discussed in our GI MDT and a decision for an abdominoperineal resection with total ileoanal pouch excision was made

The procedure was done robotically and was started with adhesiolysis and freeing of the ileoanal pouch

The pouch was then dissected freely up to to the pelvic floor.

Then resection of the anorectal stump was carried out transperineally. An End ileostomy was fashioned on the left side of the abdomen due to the presence of parastomal hernia at the previous diverting loop ileostomy site for the initial IPAA procedure.

Patient had a smooth postop recovery and was discharged on postop day 7.

SOLID ORGANS – Thyroid

V086 - Continuous Intraoperative Neuromonitoring (C-IONM) in Minimally Invasive Video Assisted Thyroidectomy (MIVAT)

P. Papini, Andrea De Palma, A. De Palma, L. Rossi, C.E. Ambrosini, G. Materazzi

¹Azienda Ospedaliero Universitaria Pisana, Endocrine Surgery, Italy

Aim: Introducing the use of Continuous Neuromonitoring (C-IONM) in Minimally Invasive Video Assisted Thyroidectomy in order to reduce the laryngeal nerve injury rate in a more technically difficult surgical procedure

Methods: The case described in the video is a 32-year-old female patient with a 13 mm papillary carcinoma in the right lobe of the thyroid gland. Acconding to the American Thyroid Association Guidelines the surgical indication was right lobectomy.

Results: A 1.5 cm horizontal skin incision is performed roughly 2 cm above the sternal notch in the central cervical area. The strap muscles are divided and the right lobe of the thyroid is dissected using an atraumatic endoscopic spatula. The operative space is established in order to provide access to all critical structures for the endoscopic part of the procedure. A 30-degree 5-mm endoscope is introduced and the carotid sheath is dissected in order to isolate the vagus nerve. A first intermittent stimulation is performed (V1). Automatic Periodic Stimulation (APS) electrode is placed around the vagus nerve and the continuous neuromonitoring starts. The right lobe is pulled caudally and the upper pedicle is isolated and sealed by an ultrasonic device. The thyroid lobe is then pulled medially by army navy retractor. This maneuver leads to a possible stretching of the nerve resulting in a reduction of the amplitude and an increase in the latency of the electromyographic signal recorded by the C-IONM. In order to prevent a complete loss of signal the retractor is placed in a different position. The recurrent laryngeal nerve is visualized and elecromyographical signal is recorded (R1). The upper pole is furtherly retrieved by rotating the lobe and sectioning isthmus and Berry ligament. The right lobe-isthmusectomy is completed under direct vision. According to standard IONM procedure the post-dissection signals (R2, V2) are recorded. APS is then removed.

Conclusions: C-IONM is a feasible improvement in thyroid surgery and it can be used safely also in minimally invasive procedures. The traction requested during the surgery can lead to an injury of the inferior laryngeal nerve and C-IONM can avoid potentially permanent lesions of the nerve.

SOLID ORGANS – Parathyroid

V088 - A case of Minimally Invasive Video-Assisted Parathyroidectomy (MIVAP) with intraoperative parathyroid autofluorescence detection

Zaira Pellin, C. Dobrinja, N. de Manzini

¹University of Trieste, Clinic Surgery, Italy

The minimally invasive video-assisted parathyroidectomy (MIVAP) is a validated option for the treatment of primary hyperparathyroidism sustained by a single adenoma, with an improved early postoperative course and cosmetic outcomes.

We presented a case of a patient with a recent diagnosis of primary hyperparathyroidism underwent a MIVAP with anterior approach. The patient was previous operated by total thyroidectomy for a goiter. The preoperative 99mTc-SestaMIBI scintigraphy found an enlarged and parathyroid gland, compatible with an adenoma, in the left retroclavear site. We proceeded with the excision of the previous scar and the introduction of a 5 mm and 30 degrees laparoscope optique to magnify the images. Because of the mediastinal position of the parathyroid, the camera was held on at the head of the patient to permit a better visualization. Dissection of the tissue was performed until the visualization of the pathological gland. Intraoperatively, imaging of the autofluorescence of the tissue was captured to confirm the individualization of the parathyroid gland. Also, the IOPTH levels was measured at time zero, and 5 and 15 minutes after excision of the adenoma. The presence of an adenoma was confirmed by an intraoperative histopathological examination.

The MIVAP is confirmed a valid and safe surgical technique in primary hyperparathyroidism also in patient with a difficult access to the neck due to a reintervention and a mediastinal localization of the gland.

SOLID ORGANS – Adrenal

V089 - Retroperitoneal Endoscopic Adrenalectomy: What advantages does it offer?

Eugenia Butori, M. Manyalich-Blasi, P. Dominguez-Garijo, J. Ardid, D. Saavedra, R. Rull-Ortuño, O. Vidal

¹Hospital Clinic de Barcelona, Gastrointestinal and General Surgery, Spain

Aims: Retroperitoneal endoscopic adrenalectomy is a minimally invasive technique for the treatment of benign adrenal gland lesions. Compared with transabdominal laparoscopy,avoids abdominal adhesions in patients with previous surgeries, reduces the risk of visceral injury and prevents the incisional hernia. However, it may present greater technical difficulty and learning curve attributed to the limited surgical space and the need to become familiar with the retroperitoneal anatomy from an unusual point of view. The following video aims to detail the surgical technique, emphasizing the most relevant technical aspects.

Methods: We present the case of a 46-year-old man with history of open cholecystectomy and laparoscopic appendectomy, diagnosed with a 35x23mm right adrenal mass suspected of non-functioning adenoma. After evaluation in a multidisciplinary committee, he is proposed for retroperitoneal endoscopic adrenalectomy.

With the patient in prone position with hip flexion between 30 and 45º, a 12mm trocar for the optic is placed in the lower margin of the 12th rib. Through blunt dissection it is created a virtual cavity between the ribs, the kidney and the diaphragm and a second 5mm trocar is placed at the posterior axillary line. CO2 is insufflated at a pressure of 25mmHg and the third 12mm trocar is placed parallel to the paravertebral muscles under direct vision.

Using high-energy sealing devices, Gerota's fascia is dissected, until the upper pole of the kidney where the adrenal gland is identified. Next, the inferior vena cava is identified, where the right adrenal vein drains, which is sealed and divided. The dissection of the adrenal gland should be performed from caudal to cranial, so that it remains attached throughout the procedure, facilitating its mobilization.

Results and conclusions: The procedure was carried out without incident and the patient had a correct postoperative period, being discharged after 48 hours. Pathological anatomy revealed an adrenal adenoma without signs of malignancy.

Retroperitoneal endoscopic adrenalectomy is a safe and feasible technique for the treatment of benign lesions of the adrenal gland, with the benefits associated to a minimally invasive endoscopic procedure. It should be indicated in patients with previous abdominal surgeries and bilateral adrenal lesions smaller than 7cm.

SOLID ORGANS – Kidney

V091—Posterior Retroperitoneoscopic Nephron-Sparing Surgery for the Resection of a Large Right Kidney Clear Cell Carcinoma

Aristotelis Kechagias ¹ , N. Kritikos¹, L. Mpoutas², V. Kyriakopoulos³, R. van Hillegersberg⁴, I. Borel Rinkes⁴, M. Vriens⁴

¹Metropolitan General Hospital, Department of Minimally Invasive Surgery, Greece, ²Metropolitan General Hospital, Department of Urology, Greece, ³Metropolitan General Hospital, Department of Anesthesia, Greece, ⁴UMC Utrecht, Department of Minimally Invasive Surgery, The Netherlands

Aim: The main modalities for minimally-invasive partial nephrectomy are the transperitoneal and the lateral retroperitoneal approach. Despite its multiple potential benefits, the posterior retroperitoneoscopic technique is not popular for nephron-sparing surgery in adults as the working space is limited and intracorporeal suturing is challenging. To the best of our knowledge, the posterior retroperitoneoscopic technique has been described by a case report (Davies et al, Urology 2007) for the resection of a 1.6cm tumor at the posterior aspect of the kidney without the necessity for suturing. Here, we demonstrate the feasibility and safety of the Posterior Retroperitoneoscopic Nephron-Sparing Surgery (PRNSS) for the resection of a 7-cm Bosniak IV cystic neoplasm at the anterior surface of the right kidney.

Video: The patient is a 45 year-old healthy woman with the anamnesis of an open gynecologic surgery. CT-scan captions show a large tumor arising centrally from the anterior aspect of the renal hilum. The patient is placed in a prone position. Three ports are placed at the posterior subcostal area and retroperitoneal space is bluntly achieved. The whole kidney is mobilized (Retroperitoneal Space-Enhancing Kidney Total-Release - RSEKTR). The vena cava and the right renal vein and artery are dissected free, and the ureter is identified. Lymphnode sampling is performed. The right renal vein and artery are clamped. The tumor is resected and placed in an endo-bag. The open anterior surface of the kidney is sutured using a double layer and a hemostatic agent is placed. The vessels are declamped (ischemia time 30 minutes). The endobag is removed. Blood loss is minimal. Histology showed a T2N0 grade I Clear cell carcinoma with free resection margins.

Conclusion: Posterior retroperitoneal total nephrectomy has been used sporadically in adults for benign diseases. To the best of our knowledge this is the second known Posterior Retroperitoneoscopic Nephron-Sparing procedure and the first for the resection of a large (T2) malignant tumor and particularly from the anterior surface of the kidney and with intracorporeal suturing. PRNSS provides optimal access to the kidney vasculature. The RSEKTR mobilization facilitates access to anterior kidney lesions and intracorporeal suturing even for challenging cases.

COLORECTAL—Benign

V092—Double layered closure of enterotomy enhances supervision and safety of training in the operating theatre.

Carl Oskar Mattias Kahlin, A. Pazidis, G. Muthukumarasamy, P. Patil, S. Zino

¹Ninewells Hospital, General Surgery, United Kingdom

Aim: Surgical training including advanced laparoscopic and robotic techniques is currently dependent on simulation, wet lab courses and practise sessions. These provide the trainees with excellent introduction of the required skills and enhance their dexterity and have been shown to increase both technical and non-technical skills. Transition from these to actual operating in the operating theatre has not been clearly studied or defined. Supervision and training during this transition phase is complex and can be associated with increased risk during the learning curve of the trainee surgeon. We demonstrate our technique of enabling this transition during a complex and advanced laparoscopic technique such as intracorporeal suturing during enterotomy closure.

Methods: Supervision and training of laparoscopic intracorporeal enterotomy closure. Two layered closure is used with the first layer closed by the trainee and the second layer closed by the supervising surgeon. The roles are swapped as the trainee advances.

Results: The video demonstrates the training opportunity created by using the double layer closure of a small intestinal enterotomy during laparoscopic management of gall stone ileus in a 92-year-old patient. The surgical trainee closes the first layer using barbed suture (V-loc) (avoids knot tying for the trainee) under close supervision. The second layer is closed by the trainer demonstrating and reenforcing the training points identified during the closure of the first layer. The everted edge is buried by the second layer. Safe closure was completed, and the patient made an uneventful recovery.

Conclusion: Double layered enterotomy closure adds safety during the transition phase and can be utilised as a training tool. This method enables real time supervision of the trainee’s techniques and also provides immediate feedback opportunity while observe the trainer perform the similar steps. Double layered closure provides an excellent opportunity for the trainee to improve their dexterity and skills in a safe environment.

COLORECTAL—Benign

V093—Severe recurrent sigmo-subcutaneous fistula successfully treated with MIS fistulotomy, sigmoidectomy and laparoscopically performed hand-sewn colorectal anastomosis.

Mateusz Wityk ¹ , M. Bobowicz², K. Oliński¹, J. Feszak¹, C. Kaczmarkiewicz¹, J. Suchowiejko¹, V. Pawlukiewicz¹, M. Lewandowski¹, M. Mussur¹, T. Kasprzyk¹

¹Voivodeship Specialist Hospital of Janusz Korczak in Slupsk, General and Oncological Surgery Unit, Poland, ²Medical University of Gdansk, 2nd Department of Radiology, Poland

41 years old men with spinal muscle atrophy, triplegia, severe scoliosis and very good mental condition has presented 3 rd time in the General and Oncological Surgery Department due to recurrent sigmo-subcutaneous fistula with abscess under the abdominal skin. Patient was treated with antibiotics and percutaneous drainage two times in the past four months. Total parenteral nutrition was introduced and all diagnostic tests were performed. Patient was qualified to surgical treatment. The team performed: laparoscopic separation of the fistula, sigmoid’s perforation suturing, suturing of the peritoneal opening of fistula followed by omentopexy, peritoneal cavity drainage, and finaly, abscess drainage with negative pressure wound therapy. On the second day after surgery, due to severe diarrhea, Clostridium Difficile infection has been found. On the fourth day patient was qualified to surgery due to peritonitis symptoms. Laparoscopy was performed with diagnosis of perforated sigmoid diverticulum. Laparoscopic sigmoidectomy with laparoscopically hand-sewn end to end colo-rectal anastomosis and peritoneal cavity drainage was performed. After the surgery the patient's condition has improved. C. Difficile infection was successfully treated with Vancomycin. Patient was discharged home on the 16th day after surgery.

COLORECTAL—Benign

V094—Laparoscopic Sigmoidectomy of an Ischaemic Sigmoid Colon Volvulus. A Different Approach to Laparotomy

Meritxell Font, M. Bardají, M. Güell, C.A. Guariglia, S. Pardo, A. Osorio, L. Sanchón, P. Collera

¹Xarxa Assistencial Althaia, General Surgery, Spain

Aims: We present a clinic case of a patient with 4 days of constipation without abdominal pain. After some tests, an ischaemic sigmoid colon volvulus was diagnosed.

Methods: A 79 year-old man was admitted for rhinorrhoea with increased mucus production, vomit and 4 days of constipation.

Clinically he was hemodynamically stable, afebrile, and focusing on the abdomen, he presented a normal abdominal exploration, without tenderness and with preserved peristalsis. Even though he did not present abdominal pain, an X-Ray was done and it showed a dilated sigmoid colon with coffee bean sign. Analytics only demonstrated a mild increase of inflammatory parameters.

Results: As the patient was practically asymptomatic, conservative treatment was initially performed. The rectal catheter was not productive, so a decompressive colonoscopy was indicated. The procedure showed the mucosa of sigma volvulus presented critical ischaemia signs, necrotic. For this reason, urgent surgery was mandatory. Laparoscopic sigmoidectomy with end-to-end stapled anastomosis was performed. To reduce the risk of contamination the two ends were closed with staplers before doing the anastomosis, and prophylactic ileostomy was executed.

The postoperative period ran without complications, so on the 7th day, he was discharged from the hospital.

Conclusions: Sigmoid colon volvulus implicates a colon and his own mesenteric rotation, causing a closed-loop. What is important to remark is the absence of abdominal clinic in the patient, although he presented an ischaemic colon volvulus. And with these severe intestinal change, mortality rates reaches up to 11-80%.

Due to being a severe condition, it needs an early diagnosis and management. There has been some debate in treatment. Emergency surgery is required for patients with peritonitis, bowel gangrene, perforation or unsuccessful conservative treatment. The procedure will be chosen according to the patient characteristics. In the revised literature, laparotomic approach is the most usual technique, but in this case a laparoscopic treatment with obvious advantages for the patient was performed. There are several options such as Hartmann surgery, sigmoidectomy with anastomosis with or without prophylactic ileostomy.

COLORECTAL—Benign

V095—Laparoscopic Emergency Right Colectomy in Colonic Perforation Following Blunt Abdominal Trauma

Andrea Biancucci, A. Fassari, M.M. Lirici

¹San Giovanni Addolorata Hospital Complex, Department of Oncologic Surgery, Italy

In blunt trauma of the abdomen the most commonly injured organs are solid viscera’s following by those parts of gut which are fixed. Isolated colon injuries are reported very rarely in literature.

We report a case of traumatic hepatic flexure perforation in a young male patient who was successfully treated by laparoscopic approach.

A 27-years old man was admitted in emergency department after road traffic accident; physical examination and laboratory findings do not suggest abdominal involvment. CT scan revealed small amount of air in the retroperitoneal site proximum to the hepatic flexure of the colon. The procedure is accomplished through three ports, starting with ileo-caecal mobilization approaching the ileocolic mesentery and dividing the distal ileum. The posterior dissection, as usual, proceeds along the plane between the right Toldt and Gerota fasciae, freeing the lateral and anterior aspects of the duodenum. The ileocolic vein and artery are dissected free and divided. Once the hepatic flexure was mobilized, the posterior perforation of the gut was identified allowing the transverse colon division. Then an ileo-transverse intracorporeal stapled anastomosis is fashioned. The post-operative stay was uneventful with discharge on POD 4.

In well selected emergency settings, laparoscopic-assisted right colectomy can be safely performed with similar results to elective right colectomy in terms of intra-operative blood loss, postoperative complications and length of recovery. However, evidence is still lacking in regards to whether laparoscopy can safely replace traditional open surgery for patients needing emergency right colectomy.

COLORECTAL—Malignant

V096—Laparoscopic management of leak following extended right hemicolectomy and CME with resection and re-anastomosis

Ken Campbell^1,2, Ramy Shaalan ^1,2, S. Elbakri, D. Kumar, T. Khalil, R. Shaalan

¹Ninewells Hospital, General Surgery, United Kingdom, ²Ain Shams University, Egypt, General Surgery, United Kingdom

This video demonstrates laparoscopic management of anastomotic leakage following extended right hemicolectomy and complete mesocolic excision (CME) in a 77-year-old female with transverse colon cancer. For right hemicolectomy, leakage rate is reported as high as 8.1% in a recent large international audit [1]. Several studies show that laparoscopic management of anastomotic leakage following colorectal anastomosis is feasible and safe, in experienced hands. One recent study focused on this topic in right hemicolectomy with intracorporeal anastomosis as performed in this case [2].

The steps of the original resection were performed without incident, the middle colic artery was ligated at origin, ICG demonstrated perfusion in the descending colon prior to division. An intracorporeal anastomosis was completed. Initial recovery was uneventful but on day three the patient developed pain fever and peritonism. Based on these findings, immediate re-laparoscopy was planned and confirmed widespread purulent peritonitis.

The video shows the steps required in this situation (I) careful handling of the inflamed and oedematous bowel loops (II) teasing apart of the tissues forming the phlegmon to confirm the diagnosis (III) dissecting the mesentery and resection of the anastomosis with extraction via the original suprapubic extraction site (IV) aspiration of pus from subphrenic, subhepatic, pelvic and paracolic regions (V) following the entire length of small bowel to avoid interloop abscesses (VI) copious lavage of all these areas.

Thereafter the options were evaluated—in this case there was no faecal contamination and the patient’s condition remained stable. A large faecolith had impacted in the anastomosis possibly related to her psychotropic medication. After resection of the anastomosis healthy tissue was noted on either side. Due to the location, it was possible to negotiate a 29 mm circular stapler through the sigmoid colon and form a side to side circular stapled anastomosis. The patient made an uneventful recovery thereafter and was discharged 11 days later (total stay 15 days). Pathology showed a T3 tumour, none of 34 nodes were involved but EMVI was found. She was fully recovered in time to be offered adjuvant chemotherapy. Her bowel function and surveillance CT scan at 12 months were satisfactory.

[1] 2015 European Society of Coloproctology collaborating group. The relationship between method of anastomosis and anastomotic failure after right colectomy and ileo-caecal resection: an international snapshot audit. Colorectal Dis. 2017; Mar 6. https://doi.org/10.1111/codi.13646. [Epub ahead of print] PubMed PMID: 28263043

[2] Vignali, A.; Elmore, U.; Aleotti, F.; Roberto, D.; Parise, P.; Rosati, R. Re-laparoscopy in the treatment of anastomotic leak following laparoscopic right colectomy with intracorporeal anastomosis. Surg Endosc 2021 Nov;35(11):6173-6178

COLORECTAL—Malignant

V097—Neoadjuvant Radiotherapy and Laparoscopic Selective Lateral Pelvic Lymph Node Dissection: Our Strategy for Advanced Low Rectal Cancer

Shuichiro Matoba, H. Kuroyanagi, M. Ueno, S. Toda, Y. Hanaoka, Y. Fukui, K. Hiramatsu, Y. Maeda

¹Toranomon Hospital, Department of Gastroenterological Surgery, Japan

Background There is different in the treatment of low advanced rectal cancer between the Western countries and Japan. The standard treatment for advanced low rectal cancer in Westrn Countries are Neoadujvant Radiotherapy(NART) followed by Total Mesorectal Exicision(TME). Recently, it was shown that lateral pelvic recurrence after NART was the major cause of local recurrence by some reports. We thought that it was not enough NART and followed TME in case lateral pelvic lymph node (LPLN) metasatasis, so our stetoragy of advanced lower rectal cancer was NART and followed by laproscopic TME when LPLN metastasis was suspected, laparoscopic LPLN dissection (LPLND) was perfomed.

Objecives We investigate safety and feasibility of our strategy

Methods From April 2010 to December 2017, 223 patients with advanced low rectal cancer underwent curative surgery after NART. Long-course NART (45 Gy) is generally selected, however short-course NART(25 Gy) is chosen depending on individual circumstances. LPLD was performed even for the patients whose LPLN was decreased after long-course CRT. We performed using 5 port and a 10 mm flexible scope. We investigated them divided into 2 groups, enlarged LPLN(Enlarged Group) and non-enlareged LPLN(Non-Enlarged Group), respectively.

Results: There was no open conversion. Enlarged Group was 89 patients and LPLND was performed for 87 patients. Non- enlarged group was 134 patients. Median operative time was 466 and 312 min, Median blood loss was 72.5 ml and 50 ml respectively. Pathological stages of Enlarged Group included 8 ypStage0, 21 StageI, 23 ypStageII,35 ypStageIII. LPLN metastasis was pathologically proven in 23 patients. Pathological stages of Non-Enlarged Group included 8 ypStage0, 41 StageI, 45 ypStageII, 40 ypStageIII.

Postoperative complications greater than Clavien-Dindo grade III of Enlarged Group was 3 patients 5%, Non- enlarged group was 2 patients 1.9%.

Recurrence was detected in 47 patients(20.1%). Overall local recurrence of Enlarged Group and Non-Enlarged Group was detected in 8 cases (8.9%) and 5 cases(3.7%).

Conclusion Our treatment strategy for low rectal cancer is safe and oncologically feasible.

HERNIA-ADHESIONS—Emergency surgery

V098—Laparoscopic approach to diaphragmatic hernia in trauma patient

Tomasz Wikar, M. Matyja, P. Zarzycki, A. Rzepa, J. Rymarowicz, M. Pędziwiatr, P. Major

¹Jagiellonian University Hospital, 2nd Department of Surgery, Poland

Traumatic diaphragmatic hernias (TDH) occur in up to 5% cases of a blunt trauma and account for nearly 15% of penetrating injuries to the lower thorax and upper abdomen. Such incidence compels to consider diaphragmatic rupture as a possible complication in trauma patients presenting with respiratory or gastrointestinal symptoms. However, diagnosis and management of traumatic diaphragmatic hernia (TDH) may be difficult as they are often clinically masked by other associated severe injuries. Delayed diagnosis can result in higher risk of bowel strangulation or herniation of abdominal organs. In recent years laparoscopic approach was proven to be feasible and safe in the treatment of TDH.

We present a case of a 66yo male patient brought to the Emergency Department via air transport following motor vehicle accident. On admission the patient was unconscious and hemodynamically unstable with visible head and extremities injuries. In addition, computed tomography revealed diaphragmatic hernia. After initial treatment because of the insufficient ventilation patient was scheduled for urgent laparoscopic TDH repair.

Patient was placed in a French position. Four trocars were introduced. Intraoperative findings revealed a diaphragmatic hernia with a hernia sac containing greater omentum with multiple adhesions. The hernia content was reduced and the opening closed with a non-absorbable running suture. There were no postoperative complications related to the hernia repair. We believe that laparoscopic approach is a safe option in stable patients with diaphragmatic hernia.

HERNIA-ADHESIONS—Abdominal wall hernia

V100—Laparoscopic Totally Extraperitoneal Repair with Retrorectus Mesh for Concurrent Umbilical Hernia and Diastasis Recti

Panagiotis Kapsampelis, M. Gaber, I. Shah, I. Gerogiannis

¹Kingston Hospital NHS Foundation Trust, Department of Surgery, United Kingdom

Introduction/Aims: Umbilical hernias may be associated with divarication of the rectus muscle. If repaired separately, such cases can have high recurrence rates and poorer cosmetic outcomes. Therefore a combined repair of both abdominal wall defects is preferred.

This video aims to demonstrate a case of concurrent umbilical hernia and diastasis recti laparoscopic repair using a total extraperitoneal approach and retrorectus mesh placement.

Methods/Technique: Α 38-year old female presented with an umbilical hernia and diastasis recti after pregnancy, resulting in difficulty raising her body and back pain.

A left lower quadrant incision was made, and the left retrorectus space was accessed and bluntly dissected with a spacemaker balloon port. The same approach was repeated via a right lower quadrant incision for the right side. A 5 mm left lateral port was then placed at the level of the umbilicus. After dissection of the midline, the two retrorectus spaces were joined. The umbilical hernia was dissected, and the hernia sac was divided. Pneumoperitoneum was then reduced to 5 mmHg. The rectus muscles were approximated (including a bite from the linea alba) using continuous size 1 non-absorbable, barbed V-loc™ sutures. Suturing extended from the area below the xiphisternum to the infraumbilical area and included the umbilical hernia defect. Two additional ports were introduced, one in the left upper quadrant and one in the right upper quadrant, to facilitate suturing of the abdominal wall below the umbilicus. The V-loc™ suture ends were secured with Hem-o-lok clips. The posterior rectus was closed with a size 0 absorbable V-loc™ suture in a continuous manner. A 22 × 15 cm synthetic mesh (Progrip™) was deployed in the retrorectus space. Two 8-French Redivac drains were inserted via the lower ports.

Results: The patient’s postoperative course was uneventful, and she was discharged on the 2nd postoperative day. She was followed up in the outpatient clinic after 10 weeks, with no recurrence signs and excellent functional outcomes.

Discussion: Laparoscopic repair of coexisting abdominal wall pathologies such as umbilical hernia and diastasis recti is beneficial to the patient but requires advanced laparoscopic skills, expertise in complex abdominal wall reconstruction and careful patient selection.

HERNIA-ADHESIONS—Emergency surgery

V101—Emergency laparoscopic repair of strangulated inguinal hernia

Lu Yao ¹, J. Natale¹, R. Ibrahim¹, A. Butt¹, V.A. That², R. Thengungal Kochupapy¹

¹University Hospital Plymouth, General Surgery, United Kingdom, ²General Surgery, India

Aims With the increasing expertise in laparoscopic surgery, many surgeons have adopted this technique given its advantages. Although emergency repair of femoral hernia is still predominantly performed via an open approach. We present a video demonstrating an emergency laparoscopic repair of femoral hernia.

Methods Studies have found laparoscopic hernia repair is associated better patient outcomes, specifically reporting lower wound morbidity and shorter hospital stays. Perfusion of the strangulated bowel is checked using indocyanine green (ICG). If deemed viable, the hernia is reduced, and laparoscopic repair can be performed via the total extra-peritoneal (TEP) plane.

Results The patient had a quick and uneventful recovery, without requiring further laparotomy.

Conclusion Femoral hernia repair via laparoscopic approach is a feasible in emergency settings. After ensuring viability of hernia with ICG, repair can be performed via TEP method. We recommend using the laparoscopic approach in emergency repairs of femoral hernia.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V104—Laparoscopic Frey procedure with ICG fluorescence-guided biliary tract imaging

Paul Agami, M. Baychorov, R. Izrailov, I. Khatkov

¹Moscow Clinical Scientific Center, High Technology Surgery Department, Russia

This is the case of a 25-year-old male patient presenting with recurrent intractable abdominal pain he has been suffering from for the last 6 months. Three months prior to admission to our clinic the patient underwent ERCP, endoscopic stenting of the main pancreatic duct due to ductal obstruction and refractory pain. The procedure had no therapeutic effect. CT-scan showed signs of chronic pancreatitis, multiple stones from 3 to 6 mm in the pancreatic parenchyma and dilated main pancreatic duct in the head and body of the pancreas up to 10 mm and 8 mm respectively. The patient was referred for laparoscopic partial removal of the head of the pancreas with longitudinal Roux-en-Y pancreaticojejunostomy—a technique known as Frey procedure. It is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.

An adequate resection of the pancreatic head is a crucial step of this procedure. Insufficient volume of the resected pancreas and residual fibrotic tissues are the most common reasons of procedure failure, leading to pain recurrence. To perform an adequate resection, it is important to stick to the anatomical boundaries, one of which is the intrapancreatic portion of the common bile duct.

Consequently, one of the most common complications during the Frey procedure is the distal bile duct injury, which can be easily misidentified within the surrounding fibrotic tissues, developed due to chronic inflammation. A method that helps to prevent this complication is the indocyanine green (ICG) fluorescence-guided imaging, that allows to clearly visualize the biliary tract. Two hours prior to the surgery our patient received an intravenous injection of 25 mg of indocyanine green. During the resection step ICG-imaging allowed us to reveal the intrapancreatic portion of the common bile duct, thus significantly facilitating the prevention of its injury and making the resection much safer.

The purpose of this video is to demonstrate that laparoscopic Frey procedure is safe and feasible, and provides all the well-known advantages of the minimally invasive approach, particularly lower postoperative pain, earlier functional recovery, and shorter hospital stay. Also, in this particular case, we highlight the important role of ICG fluorescence-guided imaging in the prevention of one of the most serious complications—the common bile duct injury.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V105—Laparoscopic Necrosectomy approach for an Infected Walled Off Necrosis

Nubia Andrea Ramírez Buensuceso Conde ¹, A. Marmolejo Chavira¹, J.P. Serrano¹, J. Farell Rivas¹, A. Romero¹, A. Cruz Zárate¹, M.A. Rodríguez Luna²

¹Hospital Central Sur de Alta Especialidad PEMEX, Surgery, Mexico, ²IRCAD, Surgery, France

Background: Acute necrotizing pancreatitis is a disease with very broad spectrum. It can be mild, moderate, severe and fatal. Mortality of up to 35% has been described. The guidelines establish an initial expectant management, whereby four to six weeks are waited for a Walled Off Necrosis (WON) to form. Necrosis or collections are susceptible to drainage when infection has been documented, they produce compression or symptoms; or when the patient's clinical condition does not improve. During the step-up approach, percutaneous drainage is initially proposed, followed by video-assisted drainage if necessary. Sometimes percutaneous drainage is not enough to evacuate necrosis and collections, especially associated with a pancreatic fistula.

Objective: To present a retroperitoneal laparoscopic approach for the drainage of infected WON, after undergoing percutaneous drainage according to the step-up approach.

Methods: This is a 60-year-old female patient with acute necrotizing pancreatitis who presented with bilateral pleural effusion and multiple collections in the retro-gastric, spleno-renal space and left parieto-colic gutter. Six weeks after her discharge, she presented with symptoms of fever and pain. There was leukocytosis and gas in the collections on CT scan. Percutaneous drainage was performed on the left flank by placing a pig tail catheter, obtaining 300 ml of pus. Subsequently, she underwent 3 catheter changes due to interventionism without clinical improvement, with leakage in the periphery of the drainage and skin maceration. Therefore, a laparoscopic approach was decided.

During surgery, with the patient in right lateral decubitus, a 12-mm trocar guided by the interventional pig tail catheter was introduced to the retroperitoneum. CO2 was insufflated and a laparoscopic lens was introduced. A second trocar was placed under direct vision. Guided by the catheter, retrogastric and renal-spleen collections were reached, obtaining necrotic tissue and pus. Extensive washing and culture were performed. (Video)

Two blake-type drains were placed in the previous drainage site and in the accessory port. Management was started with culture-adjusted antibiotics and intramuscular octreotide 20 mg every 30 days. Nutritional intake was increased. Eroded skin care was performed with hydrocolloid patches. The amount of liquid in drainage was partially decreasing.

During the CT scan control, a decrease in collections was evidenced, with clear clinical improvement of the patient.

Conclusion: Retroperitoneal laparoscopic drainage of an infected WON is an alternative to a minimally invasive approach for patients in whom percutaneous drainage is not sufficient. Properly placed percutaneous drainage can be useful as a guide for the laparoscopic approach, increasing efficacy. More experience in this approach will be needed to validate the technique.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V106—Strategic Approach to the Splenic Vessels During Robotic Distal Pancreatectomy: Resection Versus Preservation

C. Cutolo¹, Andrea Belli ¹, R. Patrone¹, A. Albino¹, C. Cutolo¹, V. Granata¹, F. Izzo¹

¹National Cancer Institute- G. Pascale, Hepatobiliary Surgery, Italy

Aims: Describe the different types of approach to splenic vessels for lesion located in distal pancreas.

Methods: We show two clinical cases of robotic distal pancreatectomy. in the first one, we show our standardized technique of robotic distal pancreato-splenectomy with resection of splenic vessels. In the second one, we show the kimura tecnique during robotic distal pancreatectomy, with preservation of splenic vessels.

Conclusion: Depending on the type of lesion, its localization and the contact or not with splenic vessels, we can preserve or not the splenic vessels during robotic distal pancreatectomy.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V107—Techniques and management of intraoperative complications and conversions in Laparoscopic Whipple Procedure

Andrei Keidar, I. Carmeli, S. Rayman, N. Nevo

¹Assuta Ashdod Hospital, Surgery, Israel

Introduction: Pancreatoduodenectomy is considered as one of the most complex abdominal operation. Recently, laparoscopic approach has been promoted. Concerns regarding the techniques, oncologic adequacy and short term complications still exist.

Methods: This is a video compilation of a prospectively collected data and video recordings of patients who underwent an attempted laparoscopic Whipple procedure for the periampullary carcinoma between November 2017 and January 2021

Results: During this period 12 Whipple operations were attempted by laparoscopic approach. Six were converted to open, one due to anatomic variation, and one due to extensive vascular involvement by a tumor, four due to a non-progression. Five were completed in a total laparoscopic approach with all reconstructions performed intracorporeally.

Conclusion: The Laparoscopic Whipple Procedure is feasible with OR time and morbidity comparative to the open approach. The Video discusses the technical details, shows the intraoperative complications and shows the reasons for conversions, and management of intraoperative complications.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V108—Laparoscopic distal pancreatectomy and splenectomy with the utilization of the falciform ligament to reinforce the pancreatic staple line

Ioannis Siannis, D. Georgiadou, A.E. Kalligas, I. Papazacharias, K. Neokleous, N. Ntonta, G.D. Ayiomamitis

¹"Tzaneio" General Hospital of Piraeus, 1st Surgical Department, Greece

Utilization of the falciform ligament in general surgery can be traced back as far as 1978, when Fry et al. suggested its use to cover duodenal perforation due to peptic ulcer disease and it was later re-introduced by Sanderson in 1992 for laparoscopic surgery. The use of autologous materials to reinforce the pancreatic staple lines to minimize post-operative pancreatic fistulas in pancreatic surgery was firstly suggested by Iannitti et al. in 2006. Since then, the DISCOVER study has shown promising results to this novel technique.

Aims: To present our technique of Laparoscopic distal pancreatosplenectomy utilizing falciform ligament to reinforce the pancreatic staple line

Methods: A 79-year-old male patient presented with a 3 cm mass at the pancreatic tail. Using endoscopic ultrasound to obtain a biopsy (fine needle aspiration), the mass was verified as a neuroendocrine tumor. The preoperative diagnostic tests verified the absence of metastatic disease, and the patient was scheduled for laparoscopic surgery.

Results: Laparoscopic distal pancreatosplenectomy was performed using the falciform ligament to reinforce the pancreatic stapled line. Stapling was performed using a controlled compression and slow steady pancreatic transection which lasted for more than 10 min. The patient had an uneventful recovery and without presenting evidence of a pancreatic leakage or a biochemical leak and he was discharged from hospital on postoperative day 4.

Conclusions: The use of autologous materials such as the falciform ligament to reinforce the staple line during pancreatic transection has shown promising results with minimal cost and moderate difficulty to execute. In an attempt to minimize post-operative complications after pancreatic transection, this novel technique may provide promising results in the future.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V109—ICG dye, When and Why? Review in Laparoscopic Cholecystectomy

A. Bhandarwar, Aishwarya Dutt, G. Bakhshi, R. Gajbhiye, A. Wagh, S. Jadhav, A. Tandur, S. Bhondve, N. Dhimole, G. Bharadwaj, K. Reddy, H. Padekar, B. Ganesan, R. Bhatt, S. Dharmadhikari

Grant Medical College and Sir JJ Group of Hospitals, General Surgery, India

Background: Advances in minimal access surgery have made laparoscopic approach the procedure of choice for cholecystectomy. An intraoperative cholangiography technique in laparoscopic cholecystectomy involving the excretion of fluorescent indocyanine green(ICG) in the bile, after intravenous injection, has been used to determine the bile duct anatomy. It helps evaluate abnormal biliary anatomy with the patient on table and identifies pathologies like bile leaks and, rarely, retained common bile duct stones. Being concentrated in the biliary system, it is important to identify the time interval required to administer the dye before surgery for adequate visualization of the biliary tree.

Method: After complete randomization, a study group of 50 patients in group A (with ICG) and 50 in group B(without ICG) requiring laparoscopic cholecystectomy were taken up in this study. A test dose of ICG was given intradermally followed by IV administration of the dye at different intervals before the surgery for the dye to be visualized in the gall bladder intraoperatively. Using NIR imaging, the biliary tree anatomy was visualized clearly to help in dissection and clipping of the cystic duct and artery. Operative time, intra operative complications and post-operative complications were compared between the two groups. The interval between the dye administration and visualization of gall bladder anatomy during procedure was compared with previous studies.

Results: The total operative time was seen to be less in the group A (mean = 58 ± 8 min) as compared to group B (mean = 69 ± 6 min). The intra-operative blood loss and complications were more with group B (24%) as compared to group A (16%). Three out of 50 patients of group B had intra/post-operative complications of bile duct leak due to difficulty in delineating the anatomy, so were subjected to invasive procedures like ERCP and expensive investigations like MRCP. No such complications were seen in those with the usage of dye. The adequate time for ICG dye administration was observed to be about 12-18 h before the procedure.

Conclusion: Laparoscopic cholecystectomy with the usage of ICG fluoroscopy, when given 12-18 h prior to surgery, has shown to be effective for proper identification of gall bladder and bile duct anatomy during the operative procedure. This reduces intraoperative complications such as injury to cystic artery, retained common bile duct stones and bile leak.

SOLID ORGANS—Kidney

V110—Laparoscopic approach to life-threatening intraoperative bleeding, a series of clinical cases

Eduard Galliamov ¹ , M.A. Agapov², A.D. Kochkin³, R.G. Biktimirov⁴, V.P. Sergeev⁵, A.B. Novikov⁶, I.V. Meshankin⁷, A.E. Sanzharov⁸, D.I. Volodin⁹, I.Y. Volnykh¹⁰, D.R. Markaryan², V.V. Kakotkin², T.N. Garmanova²

¹Sechenov University, General Surgery, Russia, ²Medical Research and Educational Center (Lomonosov University Clinic), General Surgery and Oncology, Russia, ³RZH-Medicine, Urology, Russia, ⁴Hospital 119 FMBA of Russian Federation, Urology, Russia, ⁵Burnazyan Clinical Center of FMBA of Russian Federation, Oncourology, Russia, ⁶Clinical Hospital No. 1 of the Office of the President of the Russian Federation, Urology, Russia, ⁷Medical and Rehabilitation Center of the Ministry of Health of Russia, Urology, Russia, ⁸FSCC of FMBA of Russian Federation, Urology, Russia, ⁹GSM Clinic, Urology, Russia, ¹⁰Clinical Center RZD-Medicine, Urology, Russia

During the period of active development of minimally invasive technologies, the problem of choosing the optimal method of intraoperative hemostasis is relevant not only for graduate surgeons, but also for experienced specialists. The sudden massive intraoperative bleeding can cause challenge for team members, cause access conversion. In addition, significant intraoperative blood loss may require intraoperative hemotransfusion, which increases the risks of postoperative complications.

The video presents options for intraoperative laparoscopic hemostasis in the event of life-threatening bleeding in urology, oncology, coloproctology. Approaches for management of bleeding from the aorta, inferior vena cava, renal arteries and veins, and the inferior mesenteric artery are presented.

All operations were performed without access conversion, using a standard set of tools, no autohemotransfusion was required during the operation.

UPPER GI—Benign Esophageal disorders

V112—Robotic hiatal hernia repair in patient with intrathoracic prolapse of stomach and pancreas presenting with acute pancreatitis. A video vignette

Diego Coletta, F. Petrelli, F. Bianchini, P. A. Greco, M. L. Ricci, V. Sisti, A. Patriti

¹Azienda Ospedaliera Ospedali Riuniti Marche Nord, Chirurgia Generale, Italy

Transhiatal herniation of the pancreas is a rare complication of great hiatal hernias with about 20 cases reported in the literature from the first description in the early 90’s. Presentation of pancreatic herniation is diverse, the most common is acute pancreatitis. In the majority of cases, the pancreatic herniation is found incidentally on CT scans made for evaluating pancreatitis severity else for abdominal pain.

We present a case of a 77 years-old woman admitted to our Emergency Department for abdominal pain and vomiting. A blood exam revealed high serum level of amylases and lipase. A CT scan made to evaluate the grade of pancreatitis has shown a great hiatal hernia with the stomach and the pancreas inside. After a preoperative work-up, the patient underwent robot-assisted laparoscopic repair of the hiatal hernia with Toupet fundoplication, due to pleural opening a left chest drain was placed.

The video shows the surgical procedure step by step, the duration of surgery was 120 min.

The patient underwent an upper GI X-ray with oral contrast on the first post-operative day and then start oral intake. The postoperative course was uneventful, the chest tube was removed on the second postoperative day and the patient was discharged the day after.

UPPER GI—Gastroduodenal diseases

V113—Laparoscopic gastric resection with massive bleeding from a giant gastrointestinal stromal tumor

Alexander Voynovskiy ¹ , N. Epiphanov²

¹I.M. Sechenov First Moscow State Medical University, Abdominal, Russia, ²City Clinical Hospital named after S.S. Yudin, Abdominal, Russia

Aim: Demonstration of a clinical case of gastric resection with massive bleeding from a giant gastrointestinal stromal tumor.

Materials and Methods: 63-year-old man admitted with clinical picture of bleeding from the stomach: hematemesis, melena. Hemoglobin at admission is 42 g/l. Endoscopy revealed large submucosal neoplasm of the stomach body, CT confirmed presence of the stomach tumor, size—15 × 12 cm, circular thickening of the stomach walls. Due to recurrent bleeding and ineffective endoscopic hemostasis, laparoscopic resection of the stomach has been performed.

Results: There were installed: 2 × 10 mm trocars in the umbilical region and in the epigastrium; 5 mm trocar in the right mesogastrium; and 12 mm trocar in the left mesogastrium. Using the Ligasure apparatus, the gastrocolic ligament has been dissected, the posterior wall of the stomach has been visualized, there was cystic-solid tumor—15 × 12 cm of inhomogeneous consistency with purplish-cyanotic ischemia foci. The proximal half of the stomach has been mobilized, the left gastric artery and vein have been clipped separately, the greater curvature of the stomach has been mobilized with intersection of short branches, the intersection of the posterior gastric artery and the left gastroepiploic artery and vein. Performed resection of the stomach within healthy tissues with opening of the lumen under visual control. There were not postoperative complications. Histological findings confirmed gastrointestinal stromal tumor of the stomach.

Conclusions: The report presents a successful case of treatment of a patient with massive bleeding from a stomach tumor, with inefficient non-surgical methods of stopping bleeding, and therefore an organ-preserving laparoscopic resection of the stomach was performed with a good results.

ROBOTICS & NEW TECHNIQUES—Colorectal

V114—ENDOLAPAROSCOPIC USE OF THE HAND-X DEVICE INCLUDING FOR Transanal Minimally Invasive Surgery (TAMIS)

R. Cahill, Mohammad Faraz Khan, M.F. Khan, E. Kearns, R.A. Cahill

¹University College Dublin, UCD Centre for Precision Surgery, Ireland

INTRODUCTION The constrained access associated with Transanal Minimally Invasive Surgery (TAMIS) has encouraged surgical groups to deploy either incumbent large modular robotic-assisted ecosystems or new dedicated, complex single access platforms to offset inherent manoeuvrability limitations and skills deficits for this niche surgical indication. Here, we show instead the use of a handheld, powered laparoendoscopic 5 mm lightweight electromechanical digital device (HandXTM, Human Xtensions, Israel) that includes both hardware and software components to convert the surgeon’s hand movements precisely to the instrument-articulating tip allowing enhanced degreees of freedom and full articulation and roticulation for hook diathermy and suturing with small OR footprint.

Methods: After bench and biomedical model training, the Hand-X system was used in a series of colorectal and general procedures (n = 6) by two operating surgeons including a TAMIS excision of an early sage rectal cancer. The patient for this was an 80 year old, frail woman with co-morbidity and also an aversion to stoma formation and blood transfusion. The lesion was 2 cm in maximum dimension and was located posteriorly in the rectum, 5 cm from the anus. Standard TAMIS set-up and instrumentation (Gelport Part with Airseal) was used with the inclusion of the HandX device for initial circumferential lesion marking and thereafter haemostatic full thickness excision and defect closure. In addition, the HandX device was also used for the laparoscopic dissection components in two patients undergoing laparoscopic appendicectomy and three other patients undergoing laparoscopic cholecystectomy, laparoscopic adhesiolysis and left colonic mobilisation for a defunctioning sigmoid stoma proximal to an obstructing rectal cancer and a laparoscopic mesenteric abscess drainage and excision.

Results: All procedures were completed without intraoperative complication or undue operative prolongation with the TAMIS operating time being less than one hour. The TAMIS lesion was fully excised and the patient discharged 48 h afterwards (although did require readmission for secondary haemorrhage on postoperative day 5). No other patient suffered any surgical complication.

Conclusions: The HandX system successfully facilitated TAMIS excision among a range of other laparoscopic procedures, with the added benefit of integrating increased articulation and roticulation found in robotic surgery into endoscopic and laparoscopic procedures, without impacting on existing procedural workflows. With time dedicated to instrument understanding and training, the HandX provides an advanced solution for increased dexterity and precision directly into endolaparoscopic procedures in a more attainable and cost-effective manner than other platforms.

ROBOTICS & NEW TECHNIQUES—Colorectal

V115—Laparoscopic CME with intraoperative 3D real time navigation of the vascular anatomy

Carlo Manzo, ¹ L. Baldari¹, L. Boni¹, A. Ida¹, V. D'Abrosca¹, E. Cassinotti¹

¹Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico—Milan, General Surgery, Italy

Aim: This video shows our technique to perform laparoscopic right colectomy with complete mesocolic excision (CME) with 3D real time navigation of the vascular anatomy through the Visible Patient platform.

Methods: The patient is a 68-years-old man diagnosed with adenocarcinoma of the caecum due to onset of worsening anaemia. Contrasted enhanced thoracic and abdominal CT scan did not show distant metastases.

The patient was scheduled for laparoscopic right colectomy with CME. A preoperative 3D reconstruction of the vascular anatomy of right colic vessels was performed using the Visible Patient platform. Starting from CT scan images, this online tool provides a precise reconstruction of patient’s anatomy allowing preoperative planning and intraoperative reference to the plan. After exposure of right and transverse mesocolon, the dissection of the superior mesenteric vein started with isolation and division between clips of ileocolic vessels. The dissection proceeded with isolation and division of the right branches of the middle colic vessels. Following step was the peripancreatic dissection at the level of Henle’s trunk with the division of right colic vein. The vascular dissection was supported by the intraoperative reference to the 3D model using the visible patient platform displayed on a screen. After division of the gastrocolic ligament, the transverse colon was resected with a laparoscopic linear stapler. After blunt dissection of Toldt fascia and section of ileum mesentery, the terminal ileum was resected. The mobilization of the colon from parietal attachments was completed. A side-to-side ileo-colic intracorporeal anastomosis was performed with a surgical linear stapler. The enterotomies were closed with a double layer barbed running suture. The specimen was removed with an endobag through a suprapubic mini-laparotomy.

Results: Post-operative course was uneventful, and the patient was discharged on postoperative day five. Histopathological examination reported the presence of pT3N0 (0/58 lymphnodes) adenocarcinoma.

Conclusion: The 3D reconstruction of the vascular anatomy using the Visible Patient online platform gives advantages in preoperative planning and allows intraoperative reference to the model.

HERNIA-ADHESIONS—Emergency surgery

V116—Laparoscopic appendicectomy in third trimester of pregnancy

A. Harris, Jason George, J. George

Hinchingbrooke Hospital, General Surgery, United Kingdom

Aims: Surgery in pregnant patients involves particular risks in the third trimester due to the size of the uterus and risk of premature labour. In acute appendicitis, the traditional open procedure may be thought safer but the operative view is restricted and it can prove difficult to accurately place the incision to locate the appendix if it is displaced, while the laparoscopic approach offers recognised benefits but presents different challenges. This video presents 2 cases of acute appendicitis in pregnant patients in the third trimester. Methods: Case 1 was a 25 year old female 26 weeks pregnant with clinical signs of appendicitis. Case 2 was a 35 year old patient 32 weeks pregnant with a short history of clinical appendicitis and rising inflammatory markers. In each case after close consultation with the obstetric team and senior anaesthetic input they underwent surgery. Results: Ports were inserted with extreme care to avoid uterine trauma. In case 1, massively distended right fallopian veins were encountered which made the approach to the appendix deep behind the uterus very challenging, but after careful dissection the appendicectomy was carried out uneventfully. In case 2, a posterior appendix with perforation near to its base was found with its tip stuck in the deep inguinal ring; this was dissected free and removed in the standard way. In each case the patient made a full recovery with no adverse effects on the pregnancy. Conclusion: Laparoscopic appendicectomy is safe and feasible in third trimester pregnancy but presents significant challenges. Patients should be clearly advised of the risks, port insertion should be done with great care and surgeons should be aware of altered or displaced anatomy. It should therefore only be undertaken by experienced laparoscopic surgeons with the obstetric team involved in perioperative care and on stand-by in case of complication.

BARIATRICS—Laparoscopic

V118—Roux-Y gastric bypass—own complications

Piotr Mysliwiec ¹ , M. Lewoc²

¹Medical University of Bialystok, 1st Department of General and Endocrine Surgery, Poland, ²Oncological Hospital Bialystok, 1st Department of General and Endocrine Surgery, Poland

During my twelve years' experience in bariatric surgery, I had several complications during Roux-Y gastric bypass, including: roux limb malrotation, jejunal injury due to traction, posterior wall jejunal injury during enterotomy, pouch malformation. The video recordings of those undesired events might help others avoid similar problems.

BARIATRICS—Laparoscopic

V119—Bleeding after laparoscopic sleeve gastrectomy.

Tomasz Kozłowski ¹ , K. Safiejko¹, P. Myśliwiec²

¹Maria Sklodowska-Curie Bialystok Oncology Center, Colorectal Cancer Unit, Poland, ²Medical University of Bialystok, First Department of General and Endocrinological Surgery, Poland

We present a case of complicated laparoscopic sleeve gastrectomy performed by a surgical trainee.

The aim of our video was to show, how easily can complication occur and how hard it is to manage that problem. We found this topic to be very didactic, especially for young surgeons. During laparoscopic sleeve gastrectomy, we use harmonic scalpel, which is a very good surgical instrument, but very sensitive to tissue traction. Harmonic scalpel must be used very gently with good tissue feeling. In this case excessive traction led to bleeding in the postoperative period. Ligation of the short gastric vessels is one of the most difficult parts of sleeve gastrectomy, because the procedure is carried out in immediate proximity to the spleen and if the injury of the short vessels occurs, it can be very difficult to obtain hemostatis. In this patient, excessive traction during the use of harmonic scalpel by a junior surgeon caused bleeding from short gastric vessels. The bleeding cut ends of the short gastrics were coagulated with harmonic scalpel. As you can see in this case, the surgeons thought that the bleeding was adequately controlled and sleeve gastrectomy was continued. The leak test was negative and at the completion of initial operation no bleeding was observed. Unfortunately on the first postoperative day the patient showed signs and symptoms of active bleeding, so that the decision was made to perform re-operation. A big hematoma was found as soon as the camera was inserted into the abdomen. The suction-irrigation device was used to remove it. Progressing with re-laparoscopy, the bleeder was localized. A delta-shape liver retractor was used to retract fatty tissue obscuring the view near the spleen. Blood was coming from the cut short gastric vessels between the cardia and the superior pole of the spleen. In this case bipolar forceps were used to provide proper hemostasis. Suction, irrigation, and bipolar devices were repeatedly used to ensure that bleeding stopped. At the end hemostatic material was applied near the spleen and the drain was left in place. Postoperative period was uneventful.

BARIATRICS—Laparoscopic

V120—Leak management after Laparoscopic Sleeve Gastrectomy (LSG)

Tomasz Kozłowski ¹ , K. Safiejko¹, P. Gołaszewski², I. Diemieszczyk², P. Głuszyńska², H. Razak Hady²

¹Maria Sklodowska-Curie Bialystok Oncology Center, Colorectal Cancer Unit, Poland, ²Medical University of Bialystok, First Department of General and Endocrinological Surgery, Poland

Aims: Laparoscopic Sleeve Gastrectomy (LSG) is the most frequently performed bariatric procedure all over the world. LSG results in excellent weight loss and remission of most obesity-related comorbidities, nevertheless it can lead to serious complications. The staple line leak after LSG can appear even in 5.5% of patients and is known to be a severe complication, untreated well can be life-threatening.

Methods: This is the case of 36-year-old male patient with the BMI = 41,80 kg/m2 (183 cm height, 140 kg weight), who was admitted to the hospital for surgical treatment of morbid obesity. LSG was performed and patient was discharged in the second post-operative day with the C-reactive protein rate (36,2 mg/L) in the blood. Surprisingly, in the fourth-postoperative day, a patient was re-admitted to the hospital presenting signs and symptoms of abdominal pain, sweating, tachycardia (HR 120/min), high fever (39,5 ºC). Additional tests showed leukocytosis (WBC- 20 690/µL) and high level of C-reactive protein (CRP—385,4 mg/L) in the blood. A barium swallow fluoroscopy exam demonstrated a leak near the gastroesophageal junction. Re-laparoscopy was performed shortly, the leak was visualised, intraperitoneal lavage and drainage were performed. Nextly, self-expandable esophago-gastro-jejunal stent was inserted endoscopically. To our surprise, four weeks later, the patient was admitted to the hospital, because of nausea after every meal. Gastroscopy showed stent migration and re-insertion a stent into mid-esophagus was carried out. Nine weeks after initial insertion of a self-expandable stent, endoscopical removal of esophago-gastro-jejunal stent was done and patient was discharged from the hospital.

Results: In the 184 days follow-up, patient do not suffer of any abdominal pain. A patient has lost 41 kg, maintains healthy lifestyle and holds a diet.

Conclusion: Diagnosis and management of a leak after laparoscopic sleeve gastrectomy are demanding procedures, however immediate reoperation and early implementation of endoscopic stent placement will increase successful cure.

BARIATRICS—Laparoscopic

V121—Revisional surgery for GERD. Conversion of sleeve gastrectomy with large non-treated hiatal hernia to SADI-S. Technical aspects

Ramon Vilallonga, A. Cirera de Tudela, M. Huerta, M. Barros, A. García Ruiz de Gordejuela, O. González, E. Caubet, E. Fidilio, A. Ciudin, M. Armengol

¹Vall d'Hebron University Hospital, Endocrine, Bariatric and Metabolic Unit. Department of General and Digestive Surgery, Spain

Background: Robotic surgery is an emerging and promising technology in BC (bariatric surgery). Current studies have confirmed its feasibility and safety with a relatively short learning curve. Single-anastomosis duodenoileal shunt with vertical gastrectomy (SADI-s) is a well-known but technically challenging technique for extreme obesity in this group of patients and is therefore frequently performed as a staged laparoscopic procedure. Revision surgery for weight gain is a more technically demanding surgery that has been on the rise in recent years. The video shows a revision surgery due to weight regain and hiatal hernia of a patient with previous SG and conversion to fully robotic SADI-S (TR-SADI-S) in a patient with weight regain and hiatal hernia.

Clinical Case: A 60-year-old male patient with a baseline weight of 151 kg in 2014 and a BMI of 45 kg/m2 underwent a sleeve gastrectomy (SG). He presents progressive regain until his current weight is 123 kg and BMI 37 kg/m2. In the preoperative study, a hiatal hernia was discovered. Revision surgery is proposed for Hiatoplasty, Resleeve and conversion to fully robotic SADI-s using a Da Vinci Xi® model.

The patient is in the Trendelenburg position and on the left side. All trocars were robotic. A hiatal hernia was identified containing a remnant of the gastric fundus not dissected in the primary surgery. Content reduction and gastrectomy and hiatal closure are performed. Finally, a 270 cm ileal loop was measured to make a manual robotic duodenal-ileal anastomosis in four layers with absorbable sutures. There were no complications during or after surgery and the patient was discharged on the third postoperative day.

Conclusion: Fully robotic surgery can be safely performed through systematic stepwise progression with minimal complications and comparable surgical times. Robotic surgery appears to offer more advantages for complex cases, such as super obesity and revision surgery. More experience is needed to understand the long-term advantages and disadvantages of the fully robotic approach.

COLORECTAL—Benign

V122—Step by step technique of laparoscopic washout for diverticular perforation

K. Campbell, Sameera Sharma

¹Ninewells Hospital & Medical School, Colorectal Surgery, United Kingdom

Laparoscopic washout for diverticular perforation has the potential to avoid the morbidity of a colonic resection and a stoma. Although it has been in use for some time and been the subject of several randomised controlled trials its role remains ill defined. Guidelines from EAES/SAGES support whereas those from ACPGBI do not. One problem maybe the lack of a definition or standard for the technique. Its use in the emergency setting may also make it less certain that the requisite expertise is available.

This video shows the technique in detail as applied in the case of a 60 year old man presenting with 4 quadrant peritonitis. CT scan showed free gas and an inflamed sigmoid diverticular segment. His CRP was 330.

The principles of the technique presented here are (1) careful manipulation of inflamed oedematous bowel loops with atraumatic forceps. (2) establishing a clear diagnosis of Hinchey III and excluding Hinchey IV by dissecting the phlegmon and exposing the abscess cavity (4) fully aspirating purulent fluid from pelvis, sub phrenic, sub hepatic and para colic spaces (5) excluding residual inter loop abscesses by following the small bowel from ileo-caecal junction to duodenojejunal flexure (6) copious lavage of all the above areas (7) reassessing the site of perforation (8) drain placement to the abscess cavity.

This patient made an uncomplicated post-operative recovery with CRP returning to normal.

Follow up over several years reveals good bowel function with no further intervention required. He has been spared a colonic resection and a stoma. Failure to adhere to the above principles may be preventing this approach realising its potential to avoid morbidity in appropriate cases.

COLORECTAL—Benign

V123—COmplicated Acute Diverticulitis of the Left Colon: Is There Room for Diverticulectomy?

Claudio Antonio Guariglia, M.A. Bardaji, R.S. Farre, L.R. Sanchon, O.S. Osorio, S.A. Pardo, M.E. Font, G.Z. Gomez, C.O. Collera

¹Althaia Foundation–Manresa University Assistance Network, General Surgery, Spain

Aims: We present a video where we performed a surgical approach by mechanical intracorporeal diverticulectomy with endostapler and epiploplasty with stitches for an acute perforated diverticulitis of a single sigmoid diverticulum.

Solitary sigmoid diverticula are anecdotal and isolated diverticulectomy in complicated acute diverticulitis is a rare and controversial approach.

Methods: A 66-year-old female patient came to emergency room with intense acute pain in the lower abdomen. On examination, she presented peritonism predominantly in the left iliac fossa. Laboratory tests with leukocytosis and increased acute pase reactants. Abdominal CT scan showed diffuse pneumoperitoneum with free fluid.

Results: Urgent laparoscopy was performed, revealing purulent peritonitis in the pelvis (Hinchey III) and perforated diverticulitis of a single sigmoid diverticulum. In view of the indemnity of the rest of the sigmoid colon, mechanical intracorporeal diverticulectomy was performed with an endostapler and subsequently epiploplasty with stitches. Correct postoperative period and hospital discharge after 6 days.

Conclusions: Approximately 95% of patients with colonic diverticulosis in Western countries present diverticula in the left colon, these being multiple and most of them only in the sigma (65% of cases). The presentation in the form of isolated sigmoid diverticulum is anecdotal, being more frequent in Asian patients in the form of solitary cecal diverticulum.

Acute diverticulitis is the most common complication of left colon diverticulosis, and treatment varies according to the patient’s hemodynamic status/comorbidities and the severity of the diverticulitis.

Currently, in cases of acute diverticulitis with frank perforation and purulent peritonitis (Hinchey III), urgent surgery is recommended. If the patient presents good preoperative conditions, segmental colectomy with primary anastomosis with/without protective ileostomy is recommended, while in cases of hemodynamic instability, Hartmann's procedure is recommended.

There is low scientific evidence to support diverticulectomy in cases of single complicated diverticulum in the left colon, mainly because it is a very rare entity. However, the evidence is greater in solitary cecal diverticula which, although being mostly observational studies, present good results and may suggest that it is a plausible surgical strategy in selected cases such as the one we present in this communication.

COLORECTAL—Benign

V124—Totally laparoscopic management of gallstone ileus in a 92-year old patient with previous laparotomy performed by a trainee under supervision

A. Pazidis, Carl Oskar Mattias Kahlin, C. Kahlin, T. Nolli, S. Zino

¹Ninewells Hospital, General Surgery, United Kingdom

Background: Open approach for emergency operations are still widely adopted. Open management might be influenced by patient’s physiological status, co-morbidities, previous abdominal surgery, presence of bowel obstruction, equipment availability and the surgical expertise.

Aims: To highlight that minimally invasive surgery (MIS) in the acute setting is a good opportunity for supervised training and if widely adopted can offer great advantages to both patient and surgical trainee.

Methods: A 92y female presented with acute small bowel obstruction and severe dehydration and electrolyte disturbance. Her previous surgical history included a transabdominal hysterectomy through a left paramedian incision. IV fluid resuscitation and electrolyte correction was initiated along with NGT and urinary catheter. CT scan confirmed the diagnosis of small bowel obstruction at the level of the mid-ileum due to impacted gallstone 2.4 cm.

Results: After adequate resuscitation patient was taken to theatre for a laparoscopic operation. Pneumoperitoneum was established with a Veres needle on the left upper quadrant. This point was decided preoperatively after studying CT imaging. One 11 mm and two 5 mm ports were used, 30degree scope was used. The greater omentum was adherent to the abdominal wall along the previous incision and it was dissected. The collapsed distal small bowel was examined starting from the ileo-caecal junction and traced proximally until the impacted gall stone was identified, Videne soaked swab was placed intra abdominally in case any bowel content spilled. A laparoscopic retrieval bag was positioned in the abdomen ready to place the extracted stone. The bowel was opened longitudinally, the stone was extracted and secured in a retrieval bag and the enterotomy was closed transversely with a running absorbable barbed suture (V-lock 3-0) in two layers. The first layer was performed by the trainee and the second layer was performed by the supervising consultant. The stone was removed after being crushed successfully inside the bag to minimise wound extension.

The patient had slow uneventful post op recovery due to expected ileus. Her post op recovery and early mobilisation was great demonstration of the advantage of MIS approach

Conclusion: Bowel obstruction and previous abdominal surgery are not contra-indication for emergency laparoscopic approach. Pre-operative resuscitation, preparation, planning, and communication to facilitate holistic approach are essential in high-risk patient. From the trainee’s perspective, operations that involve intracorporeal suturing are usually more challenging and this might be a common reason to opt for open approach. This might adversely affect the patients’ good outcomes and deprive them from the possible advantages of MIS. Offering this option will enhance surgical training and prepare future consultant to be more competent and therefore more confident to proceed laparoscopically in more emergency cases.

COLORECTAL—Malignant

V125—Laparoscopic right hemicolectomy with fully hand-sewn stapler-free intracorporeal anastomosis. Description of technique, advantages, and challenges.

Ioannis Papazacharias, P. Dikeakos, A.E. Kalligas, L. Kourtidis, N. Ntonta, G.D. Ayiomamitis

¹"Tzaneio" General Hospital of Piraeus, 1st Surgical Department, Greece

Aim: Colon malignancies remain, in our days, a dominant cause of increased mortality despite outstanding scientific breakthroughs in the field. During the last two decades, the application of minimally invasive-laparoscopic surgery has had a significant impact on postoperative pain management, enhanced recovery of the patient as well as earlier bowel motility restoration, resulting in shorter hospital stay, while improving oncological validity. The conduction of the anastomosis after laparoscopic right hemicolectomy includes the decision whether to use a linear stapler or perform a hand-sewn anastomosis, intracorporeally or extracorporeally.

Our aim is to present the technique, the advantages, and the challenges of laparoscopic right hemicolectomy with fully hand-sewn stapler-free intracorporeal anastomosis.

Methods: 10 patients were submitted to laparoscopic right hemicolectomy with hand-sewn intracorporeal anastomosis.

Results: No patient presented with anastomotic leak or stenosis. No patient experienced bleeding from the anastomosis. All patients had uncomplicated postoperative course, with early bowel motility restoration, early initiation of oral feeding and physical activity, minimal pain, and better life quality.

Conclusions: Laparoscopic right hemicolectomy with fully hand-sewn stapler-free intracorporeal anastomosis is feasible and safe technique. It has all the advantages of minimally invasive surgery with much better control of bleeding at the anastomosis site and much less cost.

COLORECTAL—Malignant

V126—Our case of the successful endoscopic reconstructive stenting of the postoperative stricture of the colon after resection of sigmoid colon for cancer

Nazar Bula, Y. Macjak

¹Lviv Regional Clinical Hospital, Endoscopy, Ukraine

57 years-old patient underwent sigmoid colon resection for cancer complicated with bowel obstruction. He was performed colorectal anastomosis and transversostomy. Several courses of chemotherapy have been performed. In 6 months after surgery complete remission was achieved. The control colonoscopy revealed the complete stricture of the stapled colorectal anastomosis. The patient was sent to our clinic for endoscopic treatment and restoration of patency of the anastomosis.

The first endoscope was introduced through a transversostomy to descending colon. Colorectal anastomotic stenosis was visualized. Granulation tissues obturated the intestinal lumen. The second endoscope was introduced through the lumen of the rectum, the stricture of the anastomosis due to granulation tissues was visualized. It was not possible to pass through the total narrowing of the lumen. The contrast agent was introduced into the lumen. The lenght of the colon stricture and the direction for bougienage were determined under the X-ray control. Under the control of both endoscopes and X-ray, the stricture zone was bougienaged with guidewire 0.035. Cook Evolution Colone stent 60 mm—25 mm was placed throught the zone of stricture. Stenting was performed without complications. On colonoscopy on the 3rd day after stenting was identified patency of the stricture zone, passage through the lumen of the stent is free. Transversostomy closure operation was performed. The stent was removed under endoscope control. Physiological passage was restored.

COLORECTAL—Malignant

V127—Laparoscopic Resection for T4 sigmoid Cancer.

Bhushan Jajoo, M. Kazi, A. Mohan, A. Chatterjee, A. Desouza, A. Saklani

¹Tata Memorial Hospital, Mumbai, Colorectal Unit, India

Aims: The feasibility and safety of laparoscopic surgery in T4 colon cancer have been evaluated in many studies and found to have acceptable oncological outcomes. However, laparoscopic resection for T4 tumours is technically challenging and needs expertise in laparoscopic surgery.

In this video, we demonstrate stepwise Laparoscopic resection for T4 Sigmoid cancer.

Methods This is a single case video demonstration of laparoscopic resection for a T4 sigmoid tumour. A 48-year-old patient was evaluated for pain in the abdomen. Colonoscopy showed growth at 40 cm and biopsy revealed moderately differentiated adenocarcinoma. The CECT scan was suggestive of a non-metastatic bulky sigmoid lesion abutting the urinary bladder, involving lateral abdominal wall.

Results: This is stepwise demonstration of resection of bulky T4 sigmoid lesion involving bladder and lateral abdominal wall. Proper surgical planning and its execution help to avoid conversion.The introperative and postoperative course was uneventful. The final histopathology revealed a pT4N0 moderately differentiated adenocarcinoma with free margins.

Conclusion In this video, we have shown a step-wise approach to laparoscopic resection for T4 sigmoid colon cancer. Laparoscopic T4 colonic cancer surgery is technically challenging but should not be a reason for conversion.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V128—Laparoscopic Cholecystectomy with common bile duct injury after percutaneous cholecystostomy for acute cholecystitis in a high-risk patient

Carmen Maillo ¹ , R. Camacho Abreu¹, G. Piçarra², I. Nobre³, R. Lopes³, D. Serra⁴, N. Figueiredo¹

¹Hospital Lusíadas Lisboa, General Surgery, Portugal, ²Hospital Lusíadas Lisboa, Anesthesia, Portugal, ³Hospital Lusíadas Lisboa, Radiology, Portugal, ⁴Hospital Lusíadas Lisboa, Gastroenterology, Portugal

Introduction: Acute cholecystitis (AC) in the elderly and high risk patients may be treated by percutaneous cholecystostomy (PC) instead of laparoscopic cholecystectomy (LC) because this procedure has a lower risk to control the septic process. It is recommended to perform LC some weeks later to prevent new AC. Even if surgery is performed electively it is not simple, because those patients very frequently had symptoms during a long time and had no surgery because of the high risk and had a AC. There are no big series to describe the results of these surgeries after PC.

Material and Method: Caucasian woman 83 years old with atrial fibrillation, dyslipidemia, spinal osteoarthritis with spine surgery with anticoagulant therapy. Complaints of abdominal pain, hyperthermia, and vomiting.

Diagnosed by TAC of emphysematous cholecystitis, suspect of retrovesicular abscess and dilatation of the common bile duct of 14 mm with non pure content in the bile duct.

She was admitted in ICU and treated by PC, Endoscopic retrograde cholangiopancreatography and antibiotics.

After 5 weeks she was operated to remove the gallbladder.

Results: we present the video of the laparoscopic cholecystectomy. During the surgery it is was difficult to identify the structures and there was a section of the common bile duct. After the identification of the anatomy a Y Roux hepaticojejunostomy was performed and the cholecystectomy. The postoperative was uneventful and she was discharged 6 days later.

Conclusion: PC is lifesaving in high risks patients as demonstrated in several studies, and LC is recommended. But LC after AC and PC can be challenging and has to be performed by experienced surgeons.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V129—Re-laparoscopy for post cholecystectomy abscess

Maciej Matyja, A.L. Lasek, M.P. Pędziwiatr, A.M. Matyja

¹Jagiellonia University Medical College, 2nd Department of General Surgery, Poland

Introduction:Laparoscopic cholecystectomy has become without any doubts a golden standard. However, minimally invasive approach still remains controversial in case post-cholecystectomy complications. Re-laparoscopy is by definition more challenging, but we believe that in the hands of an experienced surgeon it can be safely performed and become a first choice in treatment of postoperative complications requiring intervention.

Aim: The aim of this video is to demonstrate the application of laparoscopic surgery for the treatment of complications after laparoscopic cholecystectomy

Methods: Patient is a 63 year- old male (BMI of 32,7 kg/m²) that underwent emergency laparoscopic cholecystectomy for gangrenous cholecystitis. Patient was readmitted on day 12 post-op with intrabdominal abscess, inflammatory markers (WBC,CRP) were elevated. The patient was qualified for re-laparoscopy. Adhesiolysis was performed, intraabdominal abscess was evacuated. No clip was found on the cystic duct. Cystic duct was dissected and clipped. Lavage and drainage were performed.

Results: Patient tolerated the procedure well. In postoperative period targeted antibiotic therapy was introduced. No additional intervention was needed. Patient was discharged on day 7 post-op.

Conclusion: Re-laparoscopy is feasible, safe and highly effective for the treatment of post cholecystectomy complications. It helps to avoid more aggressive and unnecessary procedures.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V130—Laparoscopic Subtotal Cholecystectomy: Fenestrating Versus Reconstituting Type

A. Bhandarwar¹, Balamurugan Ganesan ¹ , G. Bakhshi¹, R. Gajbhiye², A. Wagh¹, S. Jadhav¹, A. Tandur¹, S. Bhondve¹, K. Reddy¹, N. Dhimole¹, G. Bharadwaj¹, R. Bhat¹, A. Dutt¹, H. Padekar¹

¹Grant Government Medical College and Sir JJ Group of Hospitals, General Surgery, India, ²GMC Nagpur, General Surgery, India

Introduction: Laparoscopic cholecystectomy is the gold standard for the treatment of gallstones. Difficult dissection of Calot’s triangle necessitates the conversion to open. However, even after the conversion majority of cases require subtotal cholecystectomy. Laparoscopic subtotal cholecystectomy is a safe bailout technique for difficult cholecystectomy where achieving ‘critical view of safety’ is more challenging and biliary injuries are common.

Methods: A retrospective study done from 2016 to 2020 was conducted in all patients who underwent laparoscopic subtotal cholecystectomy were reviewed and analyzed. Two types of laparoscopic subtotal cholecystectomy namely fenestrating and reconstituting was done. Reconstituting subtotal cholecystectomy creates a remnant of gallbladder after excision of free, peritonealized part of gallbladder where stones may recur but risk of fistula is less. Fenestrating subtotal cholecystectomy sutures the cystic duct internally in purse-string manner where post-operative fistula incidence is higher but stones will not recur.

Results: In our study 71 patients underwent subtotal cholecystectomy. Fenestrating subtotal cholecystectomy was done in 42 patients. Reconstituting subtotal cholecystectomy was done in 29 patients. An inability to complete anatomic identification was described in patients underwent reconstituting type compared to fenestrating type (41% vs 22%). Gallbladder fibrosis was described in patients underwent fenestrating type compared to reconstituting type (29% vs 7%). Operative time was longer in reconstituting group (median = 136 min) compared to fenestrating type (median = 107 min). Bile leakage occurred more often in fenestrating group than reconstituting group (18% vs 8%). Post-operative infections were significantly low in fenestrating group compared to reconstituting group (3% vs 11%). Recurrence of biliary events occurred less often after a fenestrating subtotal cholecystectomy compared to reconstituting subtotal cholecystectomy (9% vs 18%).

Conclusion: Laparoscopic subtotal cholecystectomy provides the advantage of minimal invasive surgery. It is a safe and feasible option and prevents catastrophic biliary and vascular injuries hence reduces the conversion rates. Based on our experience, no method is superior over the other. Intra-operative findings and surgical expertise influence the type of procedure. Hence, both approaches should be seen as complementary rather than competitive.

HEPATO-BILIAIRY & PANCREAS—Gallbladder

V131—“A surprise case of double gall bladder found during laparoscopic cholecystectomy”

Jayanta Kumar Das

¹Nazareth Hospital, Shillong, General and Minimally Invasive Surgery, India

Aim: To highlight an interesting case of intraoperatively detected double gall bladder with separate cystic ducts, draining into common hepatic duct.

Methods: Author records all laparoscopic procedures performed. Incidentally this patient was found have another rudimentary gall bladder. Laparoscopic cholecystectomy procedure performed was recorded.

Results: Initially mini laparoscopic cholecystectomy was being performed for the patient. But after finding of the rudimentary second gall bladder the epigastric 3 mm port was converted to a 5 mm port and the procedure was successfully completed laparoscopically. Biopsy confirmed presence of two gall bladders.

Conclusion: The second duplicated gallbladder is always very thin walled and small (PICTURE 1). But with meticulous dissection it is possible to dissect it laparoscopically.

HEPATO-BILIAIRY & PANCREAS—Pancreas

V132—Robotic Enucleo-Resection of Pancreatic Head NET-G1

Carmen Cutolo ¹ , V. ALBINO¹, M. leongito², A. Belli¹, R. Patrone¹, V. Granata¹, R. Palaia², F. Izzo.¹

¹National Cancer Centre-G.Pascale, Hepatobiliary Surgery, Italy, ²National Cancer Centre-G.Pascale, Gastro-Pancreatic Surgery, Italy

Aims: The aim of this presentation is to describe the feasibility and the tecnical robotic approach to an esophytic lesion located in the pancreatic head, in a young patient.

Methods: We show a clinical case of patient of 30 years old, that during the routine ecotomografy discovered a lesion of 25 × 24 mm located in the pancreas head. she submitted to total body tc and mri that confirmed the only one lesion. moreover dotatoc pet demonstrated high captation nearby the nodule (suv: 40,6). considering the only one lesion, the young age of the patient and the high comorbidity related to pancreato-duodenectomy, after the multidisciplinary consuling, we decided for robotic enucleo resection of lesion.

Result: The patient was discharged on 5th post operative day, without postoperative complications. hystologic exam confirmed pancreatic net g1. at 48 months from surgery the patient was disease free.

Conclusion: Robotic enucleoresection of lesion located in pancreatic head is a feasible possibility of approach in selected case to avoid pancreatoduodenectomy.

HERNIA-ADHESIONS—Abdominal wall hernia

V133—Case of laparoscopic TAPP for management of patient with ventral hernia

Orest Lerchuk ¹ , A. Poryckyy¹, V. Khomyak², O. Lukavetskyy²

¹Lviv Regional Clinical Hospital, Department of Surgery №3, Ukraine, ²Danylo Halytskyy Lviv National Medical University, Department of Surgery №#1, Ukraine

Aim: The aim of our video presentation is to show our case of efficient laparoscopic TAPP treatment of patient with ventral hernia.

Material and Methods: 60-years-old male patient with ventral midline hernia (M2-3 W2 R0) was admitted to Lviv Regional Clinical Hospital in may 2020. Taking into concideration disadvantages of IPOM hernia repair, we have decided to perform laparoscopic TAPP hernia repair for this case with the use of macroporous mesh.

Results: In the post operative clinical course we have all advatages of minimally invasive treatment of ventral hernias: hospital stay—1 day, sick-list—5 days, no local or systemic complications, no recurrency in 19 month follow-up.

Conclusions: Laparoscopic TAPP ventral hernia repair is efficient operation for patients with incisional, umbilical, epigastric ventral hernias.

HERNIA-ADHESIONS—Abdominal wall hernia

V135—A Case Report Of An Umbilical Hernia Repair Using Extended Totally Extraperitoneal Rives Stoppa Technique

Christie Anne Lorenzo, Y. Ventura, C. Lalas

¹Tondo Medical Center, General Surgery, Philippines

Aims: The European Hernia Society classification for abdominal wall hernias defines umbilical hernia as hernia located from 3 cm above to 3 cm below the umbilicus. Umbilical hernias in adults are acquired in 90%, with incidence in general population of 2% while it is more common in obese and multiparous patients. There is a considerable debate about the best technique used to repair hernias. The Rives-Stoppa repair is a sublay technique of hernia repair, and has a recurrence rate of 0-8%. Commonly, this type of repair is done using a laparotomy incision. We aim to analyze the outcome of this technique performed laparoscopically as to its recurrence rates, quality of life, hospital length of stay, and infection rate.

Methods: We review a case of a 44 year old male with umbilical hernia who presented with a 2.5 cm reducible protruding umbilical mass, with no history of previous operations. The patient underwent an extended totally extraperitoneal repair (eTEP) using Rives Stoppa technique. Blunt dissection of the retromuscular space using a 0 degree scope was done. The incarcerated omentum was reduced and the posterior fascial defect was closed. Linea alba was reconstructed and a prosthetic mesh was placed on the retromuscular position.

Results: The overall postoperative outcome of the patient was excellent. Minimal pain on post-operative site was noted. The patient was progressed to full diet within 12 h, and was discharged on post-operative day 2. The patient was followed up post-operatively and is doing remarkably well, with no signs of wound infection.

CONCULUSION. The authors conclude that the Rives-Stopped repair via e-TEP is a favorable method for reconstruction of umbilical hernia defects. While it is a promising technique for low recurrence rate, excellent long-term results and minimal morbidity, the added benefits from the laparoscopy technique also allows shorter recovery period and less wound infection rate.

HERNIA-ADHESIONS—Abdominal wall hernia

V136—Emergency Laparoscopic Parastomal Hernia Repair

Alfred Butt, J. Natale, R. Ibrahim, L. Yao, V. Thota, R. Thengungal Kochupapy

¹University Hospitals Plymouth NHS Trust, Colorectal, United Kingdom

Aims To demonstrate a safe and effective method for laparoscopic parastomal hernia repair for use in the emergency or elective setting.

Methods Entry to the abdominal cavity was gained using VisiPort technique. The parastomal hernia defect was identified and small bowel adhesiolysis performed to free the bowel from the sac. Once the hernia is reduced the defect is repaired using V-lock suture and a DynaMesh secured with ProTack.

Results Emergency laparoscopic parastomal hernia repair resulted in a satisfactory result and safe discharge in this patient with no further intervention required.

Conclusion Laparoscopic parastomal hernia repair, as demonstrated in this video, presents a safe and effective alternative to open surgery. This gives surgeon’s and patient’s a laparoscopic alternative option to open surgery and all the benefits this confers.

Key Statement This case and video demonstrate the safe use of laparoscopic surgery to perform a parastomal hernia repair in the emergency setting.

HERNIA-ADHESIONS—Adhesions

V137—Cutting With Care: Minimally Invasive Management of the Challenging Adhesions and Access After Prior Intraperitoneal Mesh Repair—Video Presentation

Bogdan Dumbrava, F. Turcu, C. Copaescu

¹Ponderas Academic Hospital, General Surgery, Romania

Aims The expanding number of patients with prior intraperitoneal mesh repair builds the opportunity for the general surgeon to face the need for re-laparoscopy for another pathology. In this commented video recording we are showing the issues experienced during access in the peritoneal cavity and while performing the dissection of adhesions.

Methods We have reviewed all documents and video recordings of the patients with laparoscopic re-exploration after prior ventral or incisional hernia repair.

Results We have identified 37 cases of laparoscopic evaluation: recurrent or primary abdominal hernia repair (n = 13), mesh related sepsis (n = 6), occlusive syndrome (n = 8), bariatric surgery (n = 6) and other pathology (n = 4). The mean percentage of the area covered by the mesh was 70%. In terms of challenges and complications, conversion to robotic surgery was needed in 2(5.4%) cases and to open surgery in 3(8.1%) due to difficult adhesiolysis. There were 6(16.2%) small bowel perforations. There were no major perioperative complications related to adhesiolysis.

There are six highlights that we are considering valuable to present:

1.Difficult Dissection to IPOM mesh.

2.Grade 4 adhesions to small bowel.

3.Access cannula through omentum.

4.Access cannula through small bowel.

5.Prothesis eroding small bowel.

6.Conversion to robotic surgery.

Conclusions: The video demonstrates that the minimally invasive approach after previous abdominal wall surgery is feasible but challenging. Adherences to the mesh are expected in the majority of the cases.

HERNIA-ADHESIONS—Emergency surgery

V138—Laparoscopic transperitoneal hernia repair (TAPP) and simultaneously resection of Meckel's diverticulum—Case Report

Zsolt Madarasz

¹Klinikum Lippe, University Hospital of Ostwestfalen, Germany, General and Visceral Surgery, Germany

Aims: Presentation the safety and effectiveness of laparoscopic transperitoneal hernia repair (TAPP) approach to incarcerated inguinal hernias in the emergency setting.

Methodes: In this video presentation we report a case of a 53 year old male patient, who was initially presented to our urological clinic with acute sever pain in the left groin radiating to the testicles and accompained with nausea. In the clinical examination showed a clearly swollen, irreducible and tender inguinal hernia on the left, so that we indicated an emergency surgical therapy.

Results: Intraoperatively showed an incarcerated direct inguinal hernia with intestinal loop in the hernial sac without necrosis. Additional showed a big Meckel’s-diverticulum. It was performed a laparoscopic transperitoneal hernia repair with simultaneous resection of the Meckel’s divertikulum. The operation time was 24 min. The intraoperative and postoperative course was uneventfull. The Patient was descharged at the second postoperative day.

Conclusions: In our experience the laparoscopic transperitoneal hernia repair is a safe, feasible and effective therapeutic option for incarcerated hernias and represents the first choice in emergency setting by selected patients. The additional advantage of a laparoscopic approach is in solving another pathologies.

HERNIA-ADHESIONS—Inguinal hernia

V139—TRANS ABDOMINAL PREPERITONEAL PATCHPLASTY (TAPP) IN A CASE OF DE GARENGEOT HERNIA

C. Galdino Riva, Andrea Locatelli, A. Locatelli, M. Monteleone, S.G. Olmetti, A. Costanzi

¹Ospedale San Leopoldo Mandic, Merate (LC), UOC Chirurgia Generale, Italy

Aims: De Garengeot hernia is a femoral hernia that contains the appendix. This rare type of hernia was first described by René-Jacques Croissant De Garengeot in 1731. This kind of hernia is rare, with an estimated incidence ranging between 0.15 and 5% of all femoral hernias. We describe the accidental finding of a De Garengeot hernia in a 65 years old woman who underwent elective TAPP procedure for a right inguino-crural swelling.

Methodes: A three ports TAPP procedure was performed. Diagnostic laparoscopy showed the appendix incarcerated in the right femoral ring. A peritoneal flap was created starting from the right superior anterior iliac spine to the medial umbilical ligament. After complete reduction of the appendix, the right round ligament was transected in order to facilitate mesh placement. A 15 × 10 cm macroporus partially absorbable lightweight mesh (Ultrapro® mesh, Ethicon Inc®, Bridgewater, NJ) was placed. Absorbable tacks (Securestrap®, Ethicon Inc®, Bridgewater, NJ) were used to fix the mesh to the Cooper ligament and to close the peritoneal flaps.

Results: The procedure lasted 53 min. No intraoperative nor post-operative complications occurred. The patient was discharged on post-operative day 1 and was followed up at 2 weeks, 1 and 6 months after surgery. Neither pain nor recurrence were observed.

Conclusions: De Garengeot hernia is a very uncommon condition. TAPP procedure can be safely performed, in selected cases, according to surgeon’s expertise. Appendectomy can be avoided if no concomitant inflammation is found. Prosthetic mesh placement depends on the grade of local contamination.

ROBOTICS & NEW TECHNIQUES—Colorectal

V140—CME + D3 lymphadenectomy (CME/D3) for right-sided colon cancer surgery: step by step

Maria Magdalena Ilompart Coll

¹Hospital Clínic de Barcelona, General and Digestive Surgery, Spain

Right-sided colon cancer carries a poorer prognosis compared to left-sided and rectal malignancies. An optimal surgical treatment in these cases implies a complete resection of the tumor, including all the potentially affected lymphoadipose tissue, taking into account the “skip metastasis” or those non-consecutively affected lymph nodes. During the last decades, two novel surgical concepts have been established in order to improve oncological Results: the “complete mesocolic excision” (CME) and the “D3 or central lymphadenectomy” (D3). The latter category includes the same surgical principles of CME but adds two additional surgical manoeuvres: the excision of the lymphoadipose tissue covering both the superior mesenteric vein (or surgical trunk of Gillot) and the gastrocolic trunk of Henle. This involves a more complicated and demanding technique since a wider variation of anatomical structures of the major vessels in right colon has been well established. In fact, the most significant and dreaded events in these surgeries are vascular injuries, specially at the level of the superior mesenteric vein. Consequently, many colorectal surgeons haven’t embedded it as the standard of care for all right colon cancer patients. However, a recent meta-analysis has shown better short and long-term outcomes in patients who underwent CME/D3 compared to standard right hemicolectomy in terms of local recurrence, disease-free survival, overall survival, and skip-metastasis detection; without a significant increase in surgery time, intraoperative complications, rate of dehiscence, postoperative ileus, postoperative stay or mortality. These results, in association with population-based studies and recent RCTs favor the premise that CME/D3 should be the standard surgical technique for selected patients. At our center, in order to decrease the risk of vascular lesions and plan out the upcoming surgery, patients urdergo a preoperative vascular study using computed tomography (CT) angiography with 3D-reconstruction. In this video we show a step-by-step CME/D3 laparoscopic approach to right-sided colon cancer.

ROBOTICS & NEW TECHNIQUES—Colorectal

V141—Hybrid robotic anterior resection with TME for rectal cancer using CMR Versius Robotic Platform

Ludovica Baldari, E. Cassinotti, V. D'Abrosca, V. Messina, L. Boni

¹Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Department of Surgery, Italy

Aims: This video shows our technique to perform an anterior resection with total mesorectal excision (TME) for rectal cancer through hybrid robotic approach using the CMR Versius robotic platform.

Methods: The patient is a 67-years-old woman diagnosed with adenocarcinoma of the upper rectum. Contrasted enhanced pelvic MRI confirmed the lesion with few subcentimetric mesorectal lymph nodes. Contrasted enhanced thoracic and abdominal CT scan did not show metastases. The patient was scheduled for hybrid robotic anterior resection with TME using the CMR Versius robotic platform. The procedure started with standard laparoscopic approach using four trocars: 11 mm supraumbilical trocar, 11 mm trocar in the right flak, 12 mm trocar in the right iliac fossa, 5 mm trocar in the left flank. The mesentery of the colon was mobilized dividing the inferior mesenteric artery and the inferior mesenteric vein between clips. After dissection of Toldt’s fascia, lateral mobilization of the descending colon and splenic flexure mobilization were performed. The TME was performed using the CMR Versius robotic platform with the camera arm in the supraumbilical port, the right-hand robotic arm in the right flank port using monopolar hook and the left-hand robotic arm in the left flank using bipolar forceps. The 12 mm port was used by the assistant. The robotic arms and the camera are controlled by the surgeon at the open console. Through the use of articulated instruments, the CMR Versius provides control and dexterity, allowing an easy access to patient’s pelvis and precise mesorectal dissection. The upper rectum was divided using an articulated linear stapler. A sovrapubic mini-laparotomy was performed and rectum extracted. After completing division of the mesentery, perfusion control of descending colon was checked with indocyanine green fluorescent angiography. A colo-rectal anastomosis was fashioned using a circular stapler.

Results: The postoperative course was uneventful and the patient was discharged on postoperative day 6. Histopathological examination confirmed the presence of pT2N0 (0/27) rectal adenocarcinoma.

Conclusion: The hybrid robotic approach for anterior resection using the CMR Versius robotic platform is feasible, giving the advantages of robotic surgery for mesorectal excision without changing the standard laparoscopic approach.

ROBOTICS & NEW TECHNIQUES—Colorectal

V142—Robotic Ultra-low anterior resection with intersphicteric dissection—Steps to obtain improved functional outcome in lower rectal tumour

Anand Mohan, B. Jajoo, A. Chatterjee, M. Kazi, A. Desouza, A. Saklani

¹TMH, Surgical Oncology, India

Lower rectal tumours present unique challenge in terms of oncological and functional outcomes. Robotic allow precision surgery with adequate balance between oncological and functional outcomes. This video presents a stepwise approach to lower rectal tumours. Interphincteric dissection with stapled anastomosis is one of the alternative for lower rectal tumours. Intersphincteric resection is an another option for low rectal tumours. There is more and more evidence coming up to show that ULAR with ISD may be associated with better functional outcomes compared to ISR. Robotics with stable camera and increase dexterity allows dissection in deep narrow male pelvis.

ROBOTICS & NEW TECHNIQUES—Liver

V143—Robotic liver resection of segments 4b and 5 combined with lymphadenectomy of the hepatoduodenal ligament for stage II gallbladder cancer

Riccardo Masserano, M.F. Nicolosi, L. Portigliotti, F. Maroso, O. Soresini, O. Capone, R. Romito

¹Maggiore della Carità Hospital, Chirurgia 2, Italy

Aims Gallbladder cancer is mostly diagnosed incidentally (70%) after a routine cholecystectomy for a benign disease. Recent guidelines suggest different surgical treatments according to the TNM classification. Incidental gallbladder carcinoma (IGBC) at stage 0 and I do not require any surgical re-resection, as the 5-years survival rate ranges from 60 to 100%. Patients with stage III and IV gallbladder cancers present a very low 5-years survival rate (1-25%) despite extensive surgery. Multiple studies have shown that stage II gallbladder cancer treated with a radical cholecystectomy improve patient survival (50-80%) compared to simple cholecystectomy. We present a video of a robotic radical cholecystectomy in a patient with stage II IGBC.

Methods A 55-year-old man underwent laparoscopic cholecystectomy, the gallbladder was removed intact, inside a plastic retrieval bag. Pathology revealed a T2 IGBC. No secondary lesions were detected by a PET and CT-scan. The multidisciplinary board recommended a radical re-resection, so it was performed a robotic extended hilar lymphadenectomy and hepatic resection of segments 4b and 5.

Results Intra-operative ultrasounds showed a 7 mm hepatic nodule which was not described at pre-operative exams. Ultrasound features were unclear due to the small size and intra-operative biopsy was not recommended because of seeding risk combined with high false-negative rate for such small lesions. As R0 surgery was achievable, the planned resection was performed. Operative time was 5 h, with an estimated blood loss of 150 mL. Recovery was uneventful and the patient was discharged on the fifth postoperative day. Final pathology showed no lymph node metastasis but revealed a 7 mm liver metastasis in segment 5 with cancer free surgical margins. Multidisciplinary tumor board stated that adjuvant chemo-radiation therapy was needed.

Conclusions Robotic liver resection of segments 4b and 5 combined with Indocyanine green-guided lymphadenectomy of the hepatoduodenal ligament is safe, feasable and an oncologically appropriate technique, provided it is performed in a specialized center with experience in hepatobiliary surgery and advanced robotic surgery. This video may help oncological surgeons to perform this complex procedure.

ROBOTICS & NEW TECHNIQUES—Pancreas

V144—Robotic pancreaticoduodenectomy in situs inversus totalis

Wang Shin-E, Y-M Shyr

¹Taipei Veterans General Hospital, Surgery, Taiwan

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by right-left reversal of visceral organs and dextrocardia; the use of robotic pancreaticoduodenectomy (RPD) may be challenging in these patients. A male patient presented with jaundice; imaging studies revealed a bile duct tumor and SIT with variant celiacomesenteric trunk and multiple vascular anomalies. RPD was carried out cautiously and successfully. The trocar port design mirrored that of a normal patient. Pathological examination revealed extrahepatic bile duct adenocarcinoma, classified as pT3N1M0, stage IIB. The patient recovered uneventfully. Although difficult, RPD is technically feasible in a SIT patient with cholangiocarcinoma.

ROBOTICS & NEW TECHNIQUES—Technology

V145—INTRAURETERAL INDOCYANINE GREEN FLUORESCENCE FOR LEFT AND RIGHT URETER REAL-TIME VISUALIZATION DURING LAPAROSCOPIC LEFT HEMICOLECTOMY

Carlo Galdino Riva, A. Locatelli, M. Monteleone, S.G. Olmetti, A. Costanzi

¹Ospedale San Leopoldo Mandic, UOC Chirurgia Generale, Italy

Aims: We report two cases of patients who underwent laparoscopic left hemicolectomy in which intraoperative ureter identification was facilitated by near-infrared (NIR) light visualization after intraureteral injection of indocyanine green (ICG).

Methods: Preoperative ureteral single J stents 6 Ch × 26 cm (Vortek®) were placed. Four-ports laparoscopic left hemicolectomy was performed in both cases. Twentyfive mg of ICG powder (Verdye, Diagnostic Green GmbH®, Aschheim, Germany) were dissolved in 10 ml of a saline solution. Five ml of this ICG solution were then injected through the ureteral stent, prior to colon mobilization. Immediately the stent was closed to avoid ICG reflux in the urinary catheter. The fluorescence was detected with IMAGE1 S™ RUBINA™ system (Karl Strorz®, Tuttlingen, Germany).

Results: In the first case, surgery was performed for acute diverticulitis and we were able to identify the left ureter during the sigmoid resection. In the other case, the right ureter was identified during the isolation of a neoplastic mass conditioning right-sided hydroureteronephrosis. Ureter visualization was feasible and rapid (mean time after injection 3.2 s). In both cases, the ureter was not injured. No other complications occurred intraoperatively. Ureteral stent was removed 7 and 9 days after surgery respectively.

Conclusions: Intraureteral injection of ICG and visualization under NIR light is a safe procedure that reduces the risk of intraoperative iatrogenic ureter injury during colorectal surgery.

ROBOTICS & NEW TECHNIQUES—Technology

V146—Video Assisted Thoracoscopic Surgery(Vats) In Management Of Pulmonary Hydatid Cyst

A. Bhandarwar¹, Harshal Padekar ¹ , G. Bakhshi¹, R. Gajbhiye², A. Wagh¹, S. Jadhav¹, A. Tandur¹, E. Arora¹, S. Bhondve¹, N. Dhimole¹, K. Reddy¹, G. Bharadwaj¹, S. Dharmadhikari¹, A. Dutt¹, B. Ganesan¹, R. Bhat¹

¹Grant Medical College and Sir JJ Group of hospitals, General Surgery, India, ²Government Medical College Nagpur, General Surgery, India

Background: Hydatid cyst is a worldwide parasitic zoonotic disease. The global annual incidence of cystic echinococcus is 220 per 100,000 inhabitants in the endemic areas. The Lung is the second most common organ involved (15%) after Liver (75%). Surgical treatment along with medical therapy remains the mainstay in management of Pulmonary hydatid disease.

Conventional open thoracotomy approach has been carried out for Pulmonary hydatid cyst, Minimal Invasive Surgical approach has gained importance in recent years and needs to be explored further.

We call attention to advantages of Video assisted thoracoscopic (VATS) removal of pulmonary hydatid cysts over conventional methods in decreasing the total intraoperative time and hospital stay with an overall improved outcome.

Method: At Grant Medical College, a prospective descriptive study was conducted on 72 patients presenting between period January 2015 to January 2020 with varying sizes of pulmonary hydatids who underwent VATS assisted cystectomy for pulmonary hydatid cyst.

Out of 72, 50(70%) patients had uncomplicated hydatid cyst with average size of 5 cm, 20(27.78%) patients had complicated cyst with size > 10 cm with associated bronchiolar communication and 2 of the patients had thoracoabdominal extension of hydatid cyst through diaphragmatic defect.

Tab. Albendazole was given for 6 weeks at dose of 10 mg/kg/day preoperatively under observation.

Out of 72 cases, 67 patients underwent video assisted thoracoscopic removal of cyst (93.05%), 4 cases with complicated hydatid disease and abdominal extension underwent Video assisted thoracoscopic surgery with laparoscopic abdominal surgery (5.56%), 1 of the complicated cyst patients required conversion to open thoracotomy (1.38%) as the patient could not maintain O2 saturation.

Results: The average duration of the surgery was 94 min for single unilateral cyst, 104 min for multiple unilateral cysts, 134 min for bilateral pulmonary hydatid cysts and 163 min for converted open thoracoscopic repair. The average length of hospital stay being 7 days for video assisted thoracoscopic surgeries and 14 days for open and concomitant laparoscopic surgery. Visual analog scale score was 6.38—24 h, 4.51—48 h, 1.05—1-week post operatively. Over a follow-up period of 4 years, no recurrences were seen.

Conclusion: Minimally invasive surgery in removal of hydatid cyst is a feasible and safe operation in removal of various sizes of peripheral and central hydatid cysts. The surgery is associated with better operative and post-operative results and decreased pain.

ROBOTICS & NEW TECHNIQUES—Technology

V147—Role Of Mis In Endocrine Surgery

A. Bhandarwar¹, Aishwarya Dutt ¹ , G. Bakhshi¹, R. Gajbhiye², A. Wagh¹, S. Jadhav¹, S. Bhondve¹, N. Dhimole¹, K. Reddy¹, G. Bharadwaj¹, B. Ganesan¹, R. Bhat¹, A. Dutt¹, H. Padekar¹

¹Grant Government Medical College and Sir JJ Group of Hospitals, General Surgery, India, ²GMC Nagpur, General Surgery, India

Introduction: The advent of minimal invasive surgery in endocrinal dimensions has grown leaps and bounds. Trans-axillary (TA), Unilateral Axillo-Breast approach (UABA), Bilateral Axillo-Breast Approach (BABA), Trans-Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) are the popular procedures performed currently for thyroid and parathyroid pathologies. Trans-peritoneal and Retro-peritoneal approaches are used for adrenal pathologies. To aid to it, ICG dye helps to fast-track the procedures and makes it almost devoid of all complications.

Methods: In our ongoing 5-year study, we present a total of 226 patients, of which 119(53%) patients underwent thyroidectomy, 32(14%) patients underwent parathyroidectomy and 75(33%) patients underwent adrenalectomies. The former surgeries were performed utilizing TA approach and TOETVA approach and the latter was performed utilizing Trans-peritoneal approach. Real time angiography was done intra-operatively using Indocyanine Green (ICG) dye to delineate the vessels.

Results: Mean operative time (90 ± 15 min), estimated blood loss (18 ± 3 ml) and duration of hospital stay (3 ± 2 days) whereas post-operative complications (temporary recurrent laryngeal nerve palsy-6, temporary hypoparathyroidism-3) and cosmetic satisfaction score (2 vs 6) was low in TOETVA. Among 75 laparoscopic adrenalectomies, 39 were non-functioning tumors, 27 were phaeochromocytoma, 5 were aldosteronomas, 4 were Cushing syndrome. Mean operative duration was 129 ± 15 min. 5 patients suffered Grade I complications, with one patient suffering Grade II and IV complications each, as per Clavien-Dindo Classification.

Conclusion: Minimal invasive surgery has emerged as the standard of treatment in endocrine surgery. In all these procedures the complication rate dropped to less than 2%, decreased the overall operative time, and produced acceptable cosmetic outcomes. Introduction of Grant Medical College and JJ Hospital criteria continue to guide us and hopefully other surgeons.

ROBOTICS & NEW TECHNIQUES—Technology

V148—Bikini Line Laparoscopic Appendectomy

Andrew Fahiem, G. Nashed, M. Saber

¹Al Salam Hospital, General Surgery, Egypt

Laparoscopic appendectomy (LA) appears to have distinct advantages over open appendectomy. The laparoscopic procedures produce less pain, allow more rapid return to full activities, are associated with lower incidence of wound infection, fewer postoperative complications, better intraabdominal exploration and require shorter hospital stays. Previously, the only disadvantage to the laparoscopic approach was slightly increased operative time, however, nowadays with the increased laparoscopic training programs and the experts’ hands, LA takes less operative time.

On one hand, the first Conventional method of port insertion for laparoscopic appendectomy often result in difficult surgical access, particularly as the third port is inserted in the Rt iliac fossa. In addition, after the procedure there will be two apparent scars, one in the left iliac fossa and other in the Rt iliac fossa.. Adding to this, when a retrocecal appendix is encountered or when mobilization of the caecum becomes necessary, ergonomically it will be difficult to be done through the conventional port positions.

On the other hand, in the second common method, where a port is inserted in the supra pubic area and the other port is inserted in the left iliac fossa, although it gives the surgeon better access, however, there is still one apparent scar in the left iliac fossa. Moreover, inserting the telescope in the umbilicus does not give a proper view for the cecum and the retrocecal area.

In our study, one port will be in the umbilicus, the physiological scar of the abdomen, and the two remaining ports will be inserted in bikini line. Therefore, in our approach, there will be no apparent scars, as a result, this will be much more satisfactory for the patients due to the better cosmetic Results: Furthermore, in our study we have inserted the telescope in the left port in the bikini line and the main working hand in the umbilicus. what we have found that, ergonomically we have achieved the best access as the telescope now is between the two instruments, therefore the two azimuths angles are equally and the manipulation angle is almost 70 degrees. Adding to this, inserting the telescope in the left mid inguinal point has offered the best vision for the caecum and the retrocecal area and we now we are able to dissect the ascending colon easily.

To conclude, our new technique has delivered, not only the best cosmetic outcome, but also brilliant ergonomics compared to the previous conventional Methods. On top of that, our new technique was not ceased by any specific gender, age, height, TLC count, a particular appendicular position or the presence of appendicular mass or Abscess. Therefore, it could be said that Bikini line laparoscopic appendectomy has to become the standard technique for appendectomy.

SOLID ORGANS—Spleen

V149—Laparoscopic Splenectomy for Spleen Lymphoma

Rui Costa, Fonseca, Marinho, Graça, Barbosa

¹Centro Hospitalar Universitário de São João—Porto, Serviço de Cirurgia Geral, Portugal

Aims Spleen malignancies can be treated by laparoscopic approach with oncologic safety even in presence of splenomegaly.

Methods: We present a video of a laparoscopic splenectomy and hepatic biopsy in a 55-year-old female with Spleen Lymphoma with splenomegaly.

Results: Laparoscopic splenectomy with spleen extraction by a Pfannenstiel incision was performed without complications, and with a short hospital stay. Pathological exam confirmed the presence of a B Lymphoma with liver involvement. The patient keeps on chemotherapy.

Conclusions: Laparoscopic splenectomy is a feasible and safe in oncologic diseases with splenomegaly

UPPER GI—Benign Esophageal disorders

V150—Laparoscopic Trans Hiatal Esophagectomy with Gastric Pull Up To Neck for the Treatment of Iatrogen Esophageal Injury Post Thyroidectomy

Maher Hussein

¹American University of Beirut Medical Center, Surgery Department, Lebanon

Aims: Laparoscopic Trans Hiatal Esophagectomy with gastric pull up to neck for the treatment of Iatrogenic Esophageal injury post Thyroidectomy.

Methods: I report unusual iatrogenic injury of cervical esophagus that resulted with complete resection post total thyroidectomy for papillary CA of thyroid patient presented 4 days post surgery to our center.The video will show the steps used to treat this unusual complication by neck exploration, Laparoscopic Trans hiatal Esophagectomy with creation of gastric tube with preservation of the right gastroepiploic artery and the neck anastomosis between the cervical esophagus and stomach.

Results: Patient did well and discharged from hospital 1 week post surgery with no complication. On follow-up, Gastrograffin Swallow and CT Scan was negative for leak.

UPPER GI—Benign Esophageal disorders

V151—Laparoscopic Redo surgery for recurrent Hiatal Hernia in patient underwent a primary unknown surgical repair

Biancamaria Iacone, M. Ilardi, M. De Luca, G. Boccia, N. Pirozzi, U.Bracale, F. Corcione

¹Università degli studi di Napoli. Federico II, Puplic Health, Italy

Aims: Surgical treatment of hiatal hernia (HH) is associated with recurrence in 15-60% of cases. Redo surgery for HH is technically difficult and challenging to manage and it is recommended only in selected cases of symptomatic patients. This video shows a laparoscopic approach for HH recurrence in a symptomatic patient who previously underwent a primary unknown surgical repair.

Methods: we present a clinical case of HH recurrence in a 43-year-old female patient, operated 5 years ago with a primary unknown surgery repair. She referred persistent symptoms of gastroesophageal reflux disease (GERD) occurred in early post-operative time. Anatomical and functional assessment was performed by a CT scan, esophagogastroduodenoscopy (EGD) and barium swallow, which showed both a stenosis of the esophagogastric junction (EGJ) and prolonged esophageal transit time.

Results: Laparoscopic mesh-hiatoplasty with Toupet fundoplication was performed.The first challenge was to recognize the previous surgical treatment because of the overturned anatomy and the recurrence of a large hernia. Indeed, it was demanding to dismantle the remaining wrap and restore the native anatomy. Once that the postoperative adhesions were hardly debrided,it was clear that a Nissen fundoplication was performed. Furthermore, the hiatoplasty was technically difficult due to right diaphragmatic pillar atrophy and degeneration. It was performed with interrupted absorbable sutures and the application of a biosynthetic absorbable mesh to reinforce the hiatal orifice. At the end based on the general recommendations used on HH recurrence, a partial posterior Toupet fundoplication was performed. The patient was discharged on the seventh post-operative day and no complications were observed both post-operative and at one month follow-up. Conclusions. The video aims to describe the difficulties of the surgical technique used on a previously managed surgical site and the use of a laparoscopic access to perform it.

UPPER GI—Benign Esophageal disorders

V152—Laparoscopic resection of epiphrenic diverticulum

Imma Pros, W. Martinez, G. Sugrañes, V. Marcilla, A. Sturlese, M. Socías, C. Uribe, F. Martinez, J. Rius

¹Fundació Hospital Sant Joan de Deu de Martorell, Surgery, Spain

The epiphrenic diverticulum is a rare entity originated due a barrier motility disorder that causes herniation of the mucosa and submucosa through the muscle layers in the distal third of the esophageal lumen. In approximately 70% of patients, the epiphrenic diverticulum is in the posterior wall and on the right side of the esophagus. Most of cases are diagnosed incidentally during radiological, endoscopic examinations or for other reasons, and only already to 20% of cases are symptomatic.

It frequently is associated with achalasia, concomitant esophageal motility disorders, and a high resting pressure of the lower esophageal sphincter. Main symptoms are dysphagia, regurgitation, and bronchial aspiration. Surgical treatment is recommended only for symptomatic cases.

The laparoscopic approach is the surgical technique of choice and a long myotomy and an antireflux procedure should be added in order to prevent the development of fistulae at the site of repair of the antireflux procedure and the recurrence.

We present a case of laparoscopic repair of an epiphrenic diverticulum by laparoscopic approach.

A 46 year female patient, diagnosed because a persistent food reflux

We show the surgical technique. Hiatus disection. Epiphrenic divertirticulum disection until release of the surrounding tissue around the neck. Section whith EndoGIA. A long Heller myotomy was added, and also a anti-reflux surgery of the Toupet type.

No postoperative complications. A esophageal fluoroscopy was made at 24 h and start crushed food.

UPPER GI—Esophageal cancer

V153—Total laparoscopic and thoracoscopic Ivor Lewis esophagectomy

Carmen Maillo, R. Camacho Abreu, A. Bettencourt, G. Piçarra, N. Figueiredo

¹Hospital Lusíadas Lisboa, General Surgery, Portugal

Introduction Conventional esophageal surgery has a high index of complications. The need of abdominal and thoracic incisions produces pulmonary complications and a delay in recovery. These complications can be improved when the procedure is performed by minimally invasive surgery.

Material and Method: Caucasian 64 years old man smoker, with adenocarcinoma in the esophagogastric junction in th Z line, Siewert 2. Endoscopic ultrasound: In the esophago-gastric junction (38 cm) minimally elevated lesion com superficial ulcer of 17 mm not affecting muscularis propria and without visible adenopathy.

He did prehabilitation and smoking cessation.

Results: He was operated under general anesthesia with pulmonary exclusion performing Total laparoscopic and thoracoscopic Ivor Lewis esophagectomy. Postoperative period was uneventful and the patient was discharged in the 7 postoperative day.The video shows the preoperative exams, the different steps of the surgery and postoperative control image tests.

Conclusion: Minimally Invasive surgery for esophageal cancer is feasible and safe. This approach reduces the postoperative complications and help for a faster recovery.

UPPER GI—Gastric cancer

V154—Endoscopy guided laparoscopic trans-gastric resection of Gastro-intestinal Stromal Tumour (GIST) adjacent to the gastro-oesophageal junction

Samer Zino ¹ , D. Wu¹, R. Mapara¹, P. Fettes², S. Oglesby¹, P. Patil¹

¹Ninewells Hospital, General Surgery, United Kingdom, ²Ninewells Hospital, Anaesthetics, United Kingdom

Aim To present a novel surgical technique for resection of Gastro-intestinal Stromal Tumour (GIST) located near the gastro-oesophageal junction on the lesser curve of the stomach. The laparoscopic trans-gastric resection technique is minimally invasive and avoids partial or total gastrectomy.

Methods In this video we present the case of a 74 year old male with a body mass index of 32.3 requiring resection of a bleeding GIST. The patient presented with melaena and an upper GI endoscopy diagnosed a single 30 mm sub mucosal tumour immediately distal to the gastro-oesophageal junction. Staging CT scan excluded metastasis. The patient was consulted on the management options and decided on surgical resection for prevention of bleeding. Surgical options discussed included local resection, partial or total gastrectomy. Endoscopy was performed under general anaesthetic at the time of surgery and the tumour was found to be on the upper part of lesser curvature, thus not suitable for wedge or sleeve gastrectomy. A decision was made to utilise the trans-gastric approach. The endoscope was left in the stomach to demonstrate and protect the gastro-oesophageal junction. A gastrotomy was made longitudinally on the anterior surface of the stomach. The endoscope was used to protect the junction and an endoscopic stapler (Echelon flex 60 mm, Gold) was used to resect the tumour. A nasogastric tube (NGT) was placed under vision and the gastrotomy was closed with the stapler.

Results: The NGT was left for 72 h, controlled fluid intake started the day after the operation and gradually increased to soft diet over three days. Patient was discharged on day 4. Follow up bloods on day 7 showed WBC 10, CRP 19 and the patient was very satisfied to be at home and eating a normal diet. Using this minimally invasive approach we achieved macroscopic complete resection of the tumour whilst avoiding a total gastrectomy, admission to the high dependency unit and prolonged hospital stay.

Conclusions In this video we present endoscopy guided laparoscopic trans-gastric approach as a novel technique to avoid proximal gastrectomy or total gastrectomy in patients with tumours adjacent to the gastro-oesophageal junction that do not require radical oncological resection.

UPPER GI—Gastric cancer

V155—Laparoscopic cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion in gastric cancer

J. Nogueiro, Marisa Aral, M.A. Aral, A.O. Oliveira, H.S.S. Santos-Sousa, C.F. Fernandes, F.G. Gonçalves, A.G. Gouveia, E.B. Barbosa

¹Centro Hospitalar Universitário São João, General Surgery, Portugal

Peritoneal metastasis from gastric cancer represents advanced disease with poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemoperfusion (HIPEC) has shown survival benefit in some malignancies, but its role in the treatment of gastric cancer peritoneal metastasis is not completely elucidated. CRS-HIPEC at the time of potentially curative gastrectomy seems to add survival benefit, especially in patients with positive cytology.

Laparoscopic HIPEC (LS-HIPEC) has been investigated as a less invasive treatment option in patients with gastric cancer with limited peritoneal carcinomatosis or positive peritoneal cytology.

We aim to present a case of a 61-year-old woman with a gastric adenocarcinoma from the small curvature, with a positive cytology for tumor cells. The patient initiated chemotherapy with FOLFOX and the re-staging CT scan showed no sign of distant metastasis.

The patient was then submitted to laparoscopic cytoreductive surgery (partial parietal peritonectomy, omentectomy, distal gastrectomy, cholecystectomy, appendicectomy, partial pelvic peritonectomy, hysterectomy and bilateral anexectomy) and HIPEC with Mitomicin C and Cisplatin. All organs were then removed by transvaginal route.

Recent literature added evidence that CRS-HIPEC for peritoneal metastasis from gastric cancer leads to survival benefit for these patients. A laparoscopic approach may be an option to reduce the high postoperative burden in this population.

UPPER GI—Gastric cancer

V156—Robot assisted total gastrectomy and D2 lymphadenectomy for gastric adenocarcinoma with full robotic hand-sewn anastomosis

L. Morelli, Matteo Palmeri, N. Furbetta, S. Guadagni, G. Di Franco, M. Palmeri, A. Comandatore, M. Bianchini, L.M. Fatucchi, M. Picchi, A. Boato, G. Di Candio

¹University of Pisa, General Surgery Unit, Department of Surgery, Translational Research and New Technologies in Medicine, Pisa, Italy

Aims The da Vinci surgical System has been developed to allow an easy, mini-invasive and fast surgery, also in challenging abdominal procedures such as gastrectomy. We present here a robot assisted total gastrectomy and D2 lymphadenectomy for gastric adenocarcinoma with full robotic hand-sewn anastomosis using the da Vinci Xi.

Methods A 52-years old man with an episode of hematemesis and melena was referred to our center. A bleeding ulcerative lesion of the greater curvature of the stomach was found at the endoscopic examination (biopsy: gastric adenocarcinoma poorly differentiated). The patient underwent multidisciplinary evaluation, neoadjuvant therapy and subsequently surgical procedure. Four robotic arms and six instruments were used (monopolar scissors, Maryland bipolar forceps, prograsp forceps, Vessel Sealer Extend, needle driver and the robotic linear stapler).

Results The procedure was accomplished in 420 min. EndoWrist Vessel Sealer Extend was used to implement surgical workflow during hepatic lymphadenectomy, stomach mobilization and colo-epiploic detachment. For the reconstructive phase an hand-sewn esophagojejunostomy was performed with double layer of 3-0 V-lok, incorporating the esophageal staple line in the posterior layer of the anastomosis. No conversion to other techniques or intra-operative complications occurred. The post-operative course was uneventful. The histological examination of the specimen revealed an adenocarcinoma T3N3a, with 10/36 positive lymph nodes harvested.

Conclusion Robotic surgery for gastric cancer guarantees optimal dexterity both for dissection and for reconstruction. Particularly, in our experience the use of barbed sutures showed the required tensile strength and allowed the consistency of the necessary tension after each passage, overcoming the main drawback of robot-assisted surgery, which is absence of tactile feedback. Furthermore, the Vessel Sealer Extend could reduce the operative time during the dissection phase whereas the robotic technology improve the reconstructive phase in term of safety and maneuverability.

UPPER GI—Gastroduodenal diseases

V157—Laparoscopic duodenojejunostomy for Wilkie´s syndrome

Claudia Codina, S. Fernández-Ananín, S. González, J.C. Pernas, A. Basterra, G. Vitiello, A. Alonso, E.M. Targarona

¹Hospital de la Santa Creu i Sant Pau Universitat Autònoma de Barcelona (UAB), Department of General and Digestive Surgery. Unit of Gastrointestinal and Hematological Surgery, Spain

Aim: Wilkie´s syndrome, superior mesenteric artery syndrome (SMA) or aorto-mesenteric clamp is a rare condition of intestinal obstruction due to the compression of the third part of the duodenum between the abdominal aorta and superior mesenteric artery. The cause is believed to be the loss of fat tissue in the aortomesenteric space. The symptomatology is variable and non-specific, it goes from postprandial fulness, early satiety, nausea, and vomiting. Conservative management is considered the first step to achieve a gain weight and restore the aortomesenteric angle. When it fails, surgery is indicated.

Methods: We report a case of 24-year-old men with antecedents of anxiety and appendicectomy during childhood, who presented postprandial fullness and early satiety for five years. During last year, symptoms were getting worse with a loss of 11 kg of weight and feeding intolerance. Upper GI endoscopy did not show any abnormalities. Abdominal CT scan and barium swallow revealed gastric distention and a filiform pass of the contrast into the third portion of the duodenum. It showed an acute angle of 11° between the superior mesenteric artery and the aorta, the SMA-Aorta distance was 4.6 mm, suggesting Wilkie´s syndrome.

Conservative treatment was initially indicated, but due to the persistence of symptoms, surgery was decided. A laparoscopic side to side duodenojejunostomy with a 45 mm white load linear endostapler was performed.

Results: The surgery was performed without incidences. At the beginning of postoperative period, the patient presented gastroparesis and a paralytic ileus. Later, the patient started oral intake with an adequate digestive tolerance. Abdominal CT scan with showed a correct pass of contrast through the duodenojejunostomy.

Conclusion: The laparoscopic duodenojejunostomy is an appropriate option when surgery is indicated in Wilkie’s syndrome.

UPPER GI—Gastroduodenal diseases

V158—Mininvasive Pancreas-Sparing Duodenectomy with fully Robotic Hand-Sewn Duodenojejunal anastomosis for Gastrointestinal Stromal Tumor of the Duodenum

Virginia Gallo, A. Peri, L. Pugliese, F. Bruno, N. Mineo, M. Botti, A. Pietrabissa

¹Fondazione IRCCS Policlinico San Matteo, General Surgery, Italy

Introduction Gastrointestinal stromal tumors (GISTs) can arise in any tract of digestive system and their treatment is surgical. Duodenal GISTs are rare and their surgical resection is challenging due to the complexity of the biliopancreatic region. Several techniques have been suggested, from pancreaticoduodenectomy to limited duodenal resections and laparoscopic approach is recommended, although limited case series are reported in literature. Da Vinci robotic system is exploited especially for duodenal GIST’s enucleation; here we describe a case of laparoscopic pancreas-sparing duodenectomy (PDS) for the treatment of a GIST located between the third and the fourth duodenal tract followed by fully robotic hand-sewn end-to-end duodenojejunal anastomosis.

Material and methods On November 2020, a 51-year-old man referred to our department of General Surgery of IRCCS Policlinico San Matteo of Pavia for the treatment of a GIST of the third-fourth duodenal tract, close to pancreatic gland. It was decided to perform a laparoscopic PSD with fully robotic hand-sewn end-to-end duodenojejunal anastomosis.

Results: Postoperative course was uneventful. Liquid diet was allowed on second post-operative day and soft diet the day after. The patient was discharged on five post-operative day. Pathological findings confirmed a low-grade GIST with a very low risk of progression according to Miettinen’s classification.

Conclusion: Although our experience is limited on a single case, robot assistance proved to be effective in duodenojejunal anastomosis’ accomplishment; the enhanced dexterity conferred by robotic instruments allowed to handle and suture delicate tissues such duodenal walls gentler than in pure laparoscopy, during which the anastomosis rely on endostapler.

UPPER GI—Gastroduodenal diseases

V159—Segmental duodenal resection for metachronous gastrointestinal stromal tumor: robotic approach

Victor Holguin Arce, ¹ V. Gonzabay¹, D. Momblan¹, J.M. Balibrea Castillo¹, P. Dominguez¹, M. Caldera¹, A. de Lacy Fortuny¹

¹H Clinic Barcelona, General Surgery, Spain

Introduction and Objectives: Gastrointestinal stromal tumors (GIST) represent a rare entity with an overall incidence and prevalence estimated at approximately 1 to 1.5 per 100,000 individuals per year and 13 per 100,000, respectively.

They are tumors derived from the interstitial cells of Cajal or their precursors, and can occur in any part of the gastrointestinal tract, they present KIT (CD117) positive. The stomach is the most common site approximately 60%, followed by the jejunum and ileum. However, the duodenum is a relatively rare site, accounting for approximately 4% to 5%.

The goal of this video is to show the benefits of duodenal resection with the support of robotic technology.

Material and Methods: We present the case of a 54-year-old patient with a history of Neurofibromatosis type I, and resection of the small intestine that includes a 5 cm lesion with pathological anatomy compatible with GIST of intermediate risk, who presents during follow-up metachronous lesion in the lateral duodenal wall, at the level of the second portion, unrelated to Vater's ampulla or bile duct, PRIMOVIST MRI: Hypervascular lesion on the lateral aspect of the second duodenal portion of 17 mm compatible with GIST.

Surgical intervention is performed with the support of the Da Vinci Xi

Results: Resection was achieved without incident, the patient had a postoperative period without complications and was discharged after 48 h. The pathology report shows a Unifocal (Ki67) 2% low grade G1 tumor, with 0% risk of progression, CD117 (c-kit) AND DOG1. positive. With neoplasia-free resection margins.

Conclusions. Radical surgery is the primary treatment for potentially resectable duodenal Gist, the main objective is to achieve a complete excision of the lesion with negative microscopic margins, without performing lymph node resection, with good results with overall survival rates between 64 and 89% at 5 years of follow-up.

However, the best surgical option remains controversial, since the strategy depends not only on the size of the tumor but also on its anatomical location, surgical management varies from a major resection such as pancreaticoduodenectomy to more conservative procedures such as resection.

Robot-assisted resection has been shown to be a feasible and safe procedure, which allows a greater range of motion, being its main advantage over conventional laparoscopy.

UPPER GI—Gastroduodenal diseases

V160—Minimally invasive management of Dunbar syndrome: safety and feasibility

Chiara Caricato, G. Magno, A. G. Di Santo Albini, U. Bracale, F. Corcione

¹Federico II University Hospital, Department of Public Health, Italy

Aim: Our aim is to describe the minimally invasive surgical management of Dunbar syndrome.

Methods: Dunbar syndrome, which is also referred to as celiac axis compression syndrome, is a rare condition. The screening can be performed with duplex doppler ultrasound, which shows a peak flow higher than normal but may not clearly identify the cause of compression. The diagnosis is performed with CT examination, best noted on sagittal views.The patient, a 55-year-old female, presented to the emergency department with post-prandial colicky pain, nausea and vomiting, performed an abdominal CT-scan, which evidenced the sign of the median arcuate ligament (MAL), insertedbelow the T12, compressingupon the proximal tract of the celiac trunk. Three years after diagnosis, still complaining symptoms, she referred to the surgeon, who requested a CT angiography and indicated surgical intervention through laparoscopic debridement of the celiac trunk and section of the MAL. Pneumoperitoneum was achieved through OpenVeress Assisted technique and four trocars were introduced through the abdominal wall. The epatoduodenal ligament was identified and sectioned in its pars flaccidathrough a cordless ultrasonic dissection device. The right diaphragmatic pillar was followed on its medial margin up to the MAL. On the aortic plane the origin of the celiac trunk was detected, and the lysis of the MAL’s fibers was completed.

Results: The operative time was 30 min. Post-operative course has been regular. Right after surgery, the patient was able to move from bed, was fed with semi-liquid dietsince two hours after and was discharged during the second post-operative day. At 30 days follow-up, the patient didnot complain gastrointestinal symptoms and was following a regular diet.

Conclusions: Surgery is the only treatment of Dunbar syndrome. Laparoscopic minimally invasive approach is safe and feasible. It should be preferred, when possible, and performed by experienced surgeons.

UPPER GI—Gastroduodenal diseases

V161—Minimally invasive surgical management of Dunbar syndrome: safe and effective treatment

Chiara Caricato, G. Magno, U. Bracale, F. Corcione

¹Federico II University Hospital, Department of Public Health, Italy

Aim: Our aim is to describe the minimally invasive surgical management of Dunbar syndrome.

Methods: Dunbar syndrome, which is also referred to as celiac axis compression syndrome, is a rare condition. The screening can be performed with duplex doppler ultrasound, which shows a peak flow higher than normal but may not clearly identify the cause of compression. The diagnosis is performed with CT examination, best noted on sagittal views.

The patient, a 55-year-old female, presented to the emergency department with post-prandial colicky pain, nausea and vomiting, performed an abdominal CT-scan, which evidenced the sign of the median arcuate ligament (MAL), inserted below the T12, compressing upon the proximal tract of the celiac trunk. Symptomatic treatment of the pain and PPI were prescribed without clear benefit. Three years after diagnosis, still complaining symptoms, she was referred to our Surgical Department. A CT angiography was performed and confirmed the indication to surgical intervention through laparoscopic debridement of the celiac trunk and section of the MAL. Pneumoperitoneum was achieved through open-Veress-assisted technique and four trocars were introduced through the abdominal wall. The epatoduodenal ligament was identified and sectioned in its pars flaccida through a cordless ultrasonic dissection device. The right diaphragmatic pillar was followed on its medial margin up to the MAL. On the aortic plane the origin of the celiac trunk was detected, and the lysis of the MAL’s fibers was completed.

Results: The operative time was 30 min. Post-operative course has been regular. Right after surgery, the patient was able to move from bed, was fed with semi-liquid diet since two hours after and was discharged during the second post-operative day. At 30 days follow-up, the patient did not complain gastrointestinal symptoms and was following a regular diet.

Conclusions: Endovascular treatment is possible, but surgery is the preferred treatment of Dunbar syndrome. Laparoscopic minimally invasive approach is safe, feasible and effective. It should be preferred over open surgery, when possible, and must be performed by experienced surgeons in order to reduce the risk of incomplete treatment and recurrence.