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Informatics for the
Laparoendoscopic
Surgeon
Management of
Intraabdominal Pelvic
Catastrophes
Hernias as a Cause of
Chronic Pelvic Pain
in Women
Endoscopic
Transaxillary Near
Total Thyroidectomy
Gustavo Stringel, MD
Excerpt from Prevention and
Management, 2nd Edition
Pick from JSLS
Pick from JSLS
C. Paul Perry, MD
Juan Diego Villegas Echeverri, MD
Titus D. Duncan, MD
Ijeoma Acholonu Ejeh, MD
Fredne Speights, MD
Qammar N. Rashid, MD
Mustafa Ideis, BS
Raymond J. Lanzafame, MD, MBA
AsianAmerican MultiSpecialty Summit III – February 6-9, 2008
Laparoscopy and Minimally Invasive Surgery
a publication of the
Society of Laparoendoscopic Surgeons
Table of Contents
conferences
features
5
11
16
Informatics for the
Laparoendoscopic Surgeon
Gustavo Stringel, MD
Excerpt From Prevention and
Management, 2nd Edition
Management of Intraabdominal
Pelvic Catastrophes
Raymond J. Lanzafame, MD, MBA
Pick From JSLS
Hernias as a Cause of Chronic
Pelvic Pain in Women
C. Paul Perry, MD
Juan Diego Villegas Echeverri, MD
27
AsianAmerican Multispecialty
Summit III
Laparoscopy and
Minimally Invasive
Surgery
AsianAmerican
Honolulu, Hawaii
MultiSpecialty Summit III
February 6–9, 2008
Laparoscopy and Minimally Invasive Surgery
This event in Honolulu, Hawaii brings together
delegations of leading laparoscopists from the Pacific
Rim and Asian Oceanic Countries for a meaningful
educational and cultural exchange between surgeons
of different surgical specialties that practice minimally
invasive surgery. Plan now to attend this special event
at the Hilton Hawaiian Village Beach Resort and
Spa, Honolulu, Hawaii, USA!
February
6-9, 2008
Conference Program Directors
Harrith M. Hasson, MD
Michael S. Kavic, MD
William E. Kelley, Jr., MD
Raymond J. Lanzafame,
MD, MBA
Carl J. Levinson, MD
Elspeth M. McDougall, MD
Farr Nezhat, MD
Register now at www.SLS.org
20
Pick From JSLS
Endoscopic Transaxillary Near
Total Thyroidectomy
Titus D. Duncan, MD,
Ijeoma Acholonu Ejeh, MD
Fredne Speights, MD
Qammar N. Rashid, MD
Mustafa Ideis, BS
departments
26
Products for the Laparoscopic Surgeon
31
The Laparoscopy Web
32
Calendar of Events
Organizing Committee Chairs
Maurice K. Chung, MD
Charles H. Koh, MD
General Chair
Paul Alan Wetter, MD
presented by
the Society of Laparoendoscopic Surgeons
about the cover
The Penelope Surgical Instrument
Server (SIS) uses voice recognition,
digital cameras, and advanced image
processing software to identify surgical instruments, hand them to the
surgeon, retrieve them and put them
back in place.
On this issue’s cover, Penelope is assisting surgeon Spencer E. Amory, MD,
FACS, as he removes a lipoma from the
forearm at the Allen Pavilion of the
New York-Presbyterian Hospital in
New York City.
Dr. Amory is Chief of the Division of
General Surgery at New YorkPresbyterian Hospital/Columbia
University Medical Center and Clincial
Professor of Surgery of Columbia
University College of Physicians and
Surgeons.
The robot was designed and developed
by Robotic Systems & Technologies,
Inc., a company founded by general
surgeon, Michael Treat, MD.
laparoscopy today 1
Laparoscopy Today
Paul Alan Wetter, MD
Executive Editor
Miami, Florida
Janice Gisele Muller
Administrator of Publications
Janis Chinnock Wetter
Operations Officer
Ann Conti Morcos
Copy Editor
Flor Tilden
Director of Membership
Lauren Frede
Administrative Assistant
Connie Cantillo
Executive Assistant
Alexandra Rada
Assistant to Chairman
sls board of directors
Harrith M. Hasson, MD
President
Albuquerque, New Mexico
William E. Kelley, Jr, MD
Vice President
Richmond, Virginia
Charles H. Koh, MD
Secretary Treasurer
Milwaukee, Wisconsin
Paul Alan Wetter, MD
Chairman
Miami, Florida
sls mission statement
The Society of Laparoendoscopic Surgeons (SLS) is a non-profit, multidisciplinary
and multispecialty educational organization established to provide an open forum for surgeons and other health professionals interested in laparoscopic, endoscopic and minimally
invasive surgery.
SLS endeavors to improve patient care and promote the highest standards of practice
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A fundamental goal of SLS is ensuring that its members have access to the newest ideas and
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laparoscopy today (ISSN 1553-7080) is published twice per year by the Society of
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laparoscopy today 3
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©Copyright 2007 by SLS. For more information about the Society of Laparoendoscopic Surgeons,
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IMPACT OF INFORMATION AND COMMUNICATIONS TECHNOLOGY
Informatics for the Laparoendoscopic
Surgeon
Gustavo Stringel, MD
INTRODUCTION
Information and communication technology
(ICT) has been the driving force behind rapid
economic growth around the world. It is
“transforming social and economic activity
faster than the steam engine, railroads, and
electricity did in earlier times,” according to a
report from the US Agency for International
Development (USAID).
This recent statement by the USAID summarizes the impact of information and communication technology. The healthcare industry and
physicians have been slow to adopt ICT. A lovehate relationship has existed between physicians and information technology, especially
with the older generations. The rapid evolution
of technology has made it difficult to keep pace
with the changes. In terms of dealing with ICT,
one can quote Mohammed Ali: “You can run
but you can’t hide.” Sooner or later, all physicians must develop a sophisticated knowledge
of ICT.
It is impossible for any physician to function
without a computer. In the past few years, no
doctor’s office has been without a computer. It
is known that most health organizations spend
up to 40% of their capital budgets acquiring
and updating information technology. Medical
informatics was defined by Edward Shortliffe1
thus:
Medical informatics is the rapidly developing scientific field that deals with the storage, retrieval, and optimal use of biomedical information, data, and knowledge for
problem solving and decision making.
laparoscopy today 5
It is imperative for the laparoendoscopic
surgeon to develop knowledge and
expertise in this field to take advantage of
the new era of the information age.
Virtually all aspects of medicine or health
care have been affected by information
technology. We now see robots making
rounds and dispensing medications. Since
the inception of the newly designed PACS
(picture archiving and communication Gustavo Stringel, MD
system), radiographs can be reviewed at home,
in medical wards, in operating rooms, and virtually in every place that has a computer connected to the Internet.
EVIDENCE-BASED MEDICINE
The term “evidence-based medicine” (EBM) has
become part of everyday clinical practice. It
implies the use of current best evidence in making decisions about the care of individual
patients. Patients’ treatment should be based, to
the greatest extent possible, on evidence.2,3
In the past, most medical decisions were based
on clinical experience, guessing, folklore, tradition, nonscientific clinical observations, and the
art of medicine. With evidence-based medicine,
it is imperative to have scientific validity.2 The
availability of good, reliable information is
essential for the practice of EBM.
The principles of EBM were stated in 1980,
when the American Cancer Society developed
its guidelines for the cancer-related health
checkup:
First, there must be good evidence that each test
or procedure recommended is medically effec-
tive in reducing morbidity or mortality; second,
the medical benefits must outweigh the risks;
third, the cost of each test or procedure must be
reasonable compared with its expected benefits;
and finally, the recommended actions must be
practical and feasible.4 Many medical societies
have developed guidelines for EBM since these
first principles were stated.
that despite having the best acute medical services in the world, the overall US healthcare system is broken and fails to deliver consistent
quality, especially for patients with chronic illness.
The IOM made several recommendations,
including (1) creation of a center for patient
safety; (2) establishment of mandatory reporting via state agencies; (3) establishment of safety programs in all healthcare organizations; and
(4) passage of legislation.
Evidence-based medicine was initially defined
as opposite to clinical experience. The importance of complementing the clinical experience
with better evidence is now emphasized.5 One
In March 2003, the US House of
common implementation is the use of
Representatives Ways and Means
clinical practice guidelines in deciCommittee passed the Safety
The information
sion making to improve outcomes.
Improvement Act by a wide margin.9
age has had a
The Institute of Medicine (IOM)
It stated that within 18 months the
defines clinical guidelines as “systemmajor impact on
Secretary of Health and Human
atically developed statements to assist
medical practice. It
Services had to develop voluntary
practitioner and patient decisions
is essential for the
national standards for interoperability
about appropriate health care for spelaparoendoscopic
of health and information systems,
cific clinical circumstances.”6
specify medical terminology, and evalsurgeon to continue
Critics of clinical guidelines fear that
uate technologies like computerized
to learn and
their use and implementation will
physician order entry (CPOE) and
actively participate
lead to “cookbook medicine,” which
medication bar coding.
in this process to
will limit the use of practice experiAdverse drug effects constitute about
ensure the best
ence and thwart clinical innovation.
19% of all adverse events, the second
possible delivery of
Clinical guidelines have proliferated,
category after adverse surgical effects.
care to their
and currently guidelines are available
Approximately 30% of inpatients expefor almost every disease, with more
patients….
rience at least one adverse drug effect.
than 1000 new clinical guidelines
created annually. Guideline implementation
Despite the potential benefits of CPOE, only an
demands regular review of the scientific literaestimated 4% to 10% of US hospitals have fully
ture for necessary updates.
implemented CPOE.10 Pressure has been
increasing from the IOM and other groups to
COMPUTERIZED PHYSICIAN
implement CPOE. One of the main groups
ORDER ENTRY (CPOE)
involved in the implementation of quality
In 1999, the Institute of Medicine (IOM)
parameters including CPOE to improve quality
7
reported in the article “To err is human” that
and reduce error is the Leapfrog group. The
between 44,000 and 98,000 patients die in hosLeapfrog group is a consortium of more than
pitals every year because of medical errors. In
130 Fortune 500 companies and other large
March 2001, the IOM released a second report
private and public purchasers of health care,
on patient safety called “Crossing the quality
including AT&T, IBM, General Electric, and
chasm.”8 In summary, the IOM report states
General Motors. They use their combined pur-
6 laparoscopy today
chasing power to drive improvements in
health-care quality and safety. This group has
continuously applied pressure to health
providers to implement CPOE. To obtain
Leapfrog certification, a hospital must demonstrate that its CPOE system can intercept at
least 50% of common serious medication prescribing errors.
compliance, referral authorization, and many
others.
There has been legislative pressure to implement CPOE. The State of California passed legislation for health-care facilities to adopt a plan
for reducing medication errors by 2005. In
addition, 26 other states have passed legislation
to implement health-care safety.
Many of the HIPAA regulations deal with simple administrative policies and procedures,
such as securing patient privacy, locking office
doors, training of personnel in patient privacy,
and others. Some other requirements need
managerial and technological solutions. Some
of the issues initially designed to simplify problems have created sophisticated, expensive
complexity for the health-care provider.
The potential savings of implementing CPOE
has been emphasized mainly by reducing the
number of medication errors. It has been calculated that an average cost exists of $4,685 per
adverse drug event. CPOE should be recognized as a decision-support tool. It can be effective only after a supportive system is implemented; this includes laboratory, pharmacy,
and dietary department integration. The
human factor, not technology, is the main reason for failure. Physician participation and
ownership of the project is essential for effective CPOE implementation.11
THE HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA)
The practice of medicine has significantly
changed in the past 10 years with an increase in
the administrative and legal burdens for physicians. Managed-care organizations change
reimbursement and medical provider rules frequently. The physician has less time to spend
with the patient, because of increasing time
demands for administration and bureaucracy.
In the old times, the physician’s main focus was
treatment of the patient. Nowadays, the paradigm has shifted to administrative issues, such
as patient coverage, benefits, co-payments, formulary and nonformulary medications, HIPAA
laparoscopy today 7
The Kassembaum-Kennedy Act of 1996, also
known as The Health Insurance Portability and
Accountability Act (HIPAA), was initially
intended to simplify the overwhelming administrative processes and to improve health information security.
HIPAA has prompted new Federal regulations
requiring physicians to ensure that they are
protecting the privacy and security of patients’
medical information and using a standard format when submitting electronic transactions,
such as submitting claims to payers.
HIPAA Privacy Standards require physicians to
protect the privacy of patients’ medical information. Physicians are required to control the
ways in which they use and disclose patients’
“protected health information.” In addition,
physicians are required to offer patients certain
rights with respect to their information, such as
the right to access and copy, the right to request
amendments, and the right to request an
accounting of their charges. Finally, physicians
are required to have certain administrative protections in place (such as a privacy officer, staff
training, and implementation of appropriate
policies and procedures) to further protect
patient information.
Although HIPAA does not require physicians to
use electronic transactions, a related law, the
Administrative Simplification Compliance Act,
does impose such a requirement. The
Administrative Simplification Compliance Act
requires that all claims submitted to the
Medicare program be submitted in electronic
form. The implication of this requirement is
that because the claims are submitted electronically, they will also be required to comply with
HIPAA.
Title 45, Code of Federal Regulations (45
CFR), Parts 160 and 164: Standards for
Privacy of Individually Identifiable Health
Information; Final Rule
Statutory Background
Congress recognized the importance of protecting the privacy of health information, given the
rapid evolution of health information systems
in the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), Public
Law 104–191, which became law on August 21,
1996. HIPAA’s Administrative Simplification
provisions, sections 261 through 264 of the
statute, were designed to improve the efficiency
and effectiveness of the health-care system by
facilitating the electronic exchange of information with respect to certain financial and
administrative transactions carried out by
health plans, health-care clearinghouses, and
health-care providers who transmit information electronically in connection with such
transactions. To implement these provisions,
the statute directed HHS to adopt a suite of uniform, national standards for transactions,
unique health identifiers, code sets for the data
elements of the transactions, security of health
information, and electronic signature.
Health Insurance Portability and Accountability
Act of 1996 Summary of Administrative
Simplification Provisions
Standards for Electronic Health Information
Transactions
Within 18 months of enactment, the Secretary
of HHS is required to adopt standards from
among those already approved by private stan-
dards developing organizations for certain electronic health transactions, including claims,
enrollment, eligibility, payment, and coordination of benefits. These standards also must
address the security of electronic health information systems.
Mandate on Providers and Health Plans, and
Timetable
Providers and health plans are required to use
the standards for the specified electronic transactions 24 months after they are adopted. Plans
and providers may comply directly, or may use
a health-care clearinghouse. Certain health
plans, in particular workers compensation, are
not covered.
Privacy
The Secretary is required to recommend privacy standards for health information to Congress
12 months after enactment. If Congress does
not enact privacy legislation within 3 years of
enactment, the Secretary shall promulgate privacy regulations for individually identifiable
electronic health information.
Pre-emption of State Law
The bill supersedes state laws, except where the
Secretary determines that the state law is necessary to prevent fraud and abuse, to ensure
appropriate state regulation of insurance or
health plans, address controlled substances, or
for other purposes. If the Secretary promulgates
privacy regulations, those regulations do not
pre-empt state laws that impose more stringent
requirements. These provisions do not limit a
state’s ability to require health plan reporting or
audits.
Penalties
The bill imposes civil money penalties and
prison for certain violations.
Failure to comply with HIPAA can result in civil
8 laparoscopy today
and criminal penalties (42 USC § 1320d-5).
easy prescription and test ordering, and messag-
Violations of the Administrative Simplification
Regulations can result in civil monetary penalties of $100 per violation, up to $25,000 per
year.
ing. Other potential benefits of implementing
In June 2005, the US Department of Justice
(DOJ) clarified who can be held criminally
liable under HIPAA. Covered entities and specified individuals, as explained below, who
“knowingly” obtain or disclose individually
identifiable health information in violation of
the Administrative Simplification Regulations
face a fine of up to $50,000, as well as imprisonment up to one year. Offenses committed under
false pretenses allow penalties to be increased to
a $100,000 fine, with up to 5 years in prison.
Finally, offenses committed with the intent to
sell, transfer, or use individually identifiable
health information for commercial advantage,
personal gain, or malicious harm permit fines of
$250,000, and imprisonment for up to 10 years.
fits through more complete capture of services
ELECTRONIC MEDICAL RECORDS (EMR)
cian practices11,12.
For many years, physicians have used paperbased medical records. Some of the weaknesses
of paper-based medical records are obvious and
have become more evident in the information
age. Paper-based medical records are often illegible because of poor penmanship. They are often
ambiguous and contain incomplete information;
the clinical data are often fragmented. In addition, paper records are not readily available and
require a large space for storage. Paper-based
medical records are difficult to use to coordinate
care, routinely measure quality, or reduce medical errors.
Some of the barriers to EMR implementation
Information technology is increasingly recognized as an important tool for improving patient
safety and quality of care, and for promoting the
practice of evidence-based medicine. Electronic
medical records have great potential for improving quality.11 Some of the benefits of electronic
documentation are easy viewing, accurate and
laparoscopy today 9
EMR include analysis and reporting to improve
quality and efficiency; patient-directed functionality and billing, which can yield financial beneprovided; more defensible Medicare coding at
higher coding levels; and reductions in dataentry staff.11
Despite this potential for quality improvement,
few physician practices or health-care facilities
have embraced the use of Electronic Medical
Records. Interest in EMR is increasing among
physician groups. In a survey of 1200 mostly
solo/small physician groups, less than 13% of
respondents said that their practices had EMRs.
Thirty-two percent expressed interest in EMRs,
and half of these were “very interested.” Clearly,
EMR is of growing importance for many physi-
include high initial cost and uncertain financial
benefits, high initial physician time investment,
difficulties with technology, complementary
changes and support, and problems with electronic data exchange. Other problems include
lack of incentive and physicians’ attitudes. The
support and encouragement from physician
champions is extremely important to successful
implementation of EMR.13
CONCLUSION
The information age has had a major impact on
medical practice. It is essential for the laparoendoscopic surgeon to continue to learn and
actively participate in this process to ensure the
best possible delivery of care to their patients
and ensure compliance with new regulations.
Correspondence: Gustavo Stringel, MD, 21 Addison St,
Larchmont, NY 10538-2744, USA, Telephone: 914 493
7620, Fax: 914 594 4933, E-mail: [email protected]
Gustavo Stringel, MD, is Professor of Surgery and
Pediatrics at New York Medical College. He has published
and often presents on laparoscopy and thoracoscopy in
children. He serves on the editorial board of JSLS and sits
on the SLS Board of Trustees.
References
1. Shortliffe EH, Cimino JJ, eds. Biomedical
Informatics. Computer Applications in Health
Care and Biomedicine. 3rd ed. New York, NY:
Springer; 2006.
2. Rose JS. Medicine and the Information Age.
Tampa, FL: American College of Physician
Executives; 1998.
3. Curry W, Linney B, eds. Essentials of Medical
Management. Tampa, FL: American College of
Physician Executives; 2003.
4. Eddy DM. Evidence based medicine: a unified
approach. Health Affairs. 2005;24:9-17.
5. Timmermans S, Mauck A. The promises and pitfalls of evidence based medicine. Health Affairs.
2005;24:18-28.
6. Field MJ, Lohr KN. Clinical Practice Guidelines.
Directions for a new program. Washington, DC:
Nation Academy Press; 1990.
7. Institute of Medicine Committee of Quality
Health Care in America. To Err is Human:
Building a Safer Health System. Washington, DC:
National Academy Press; 1999.
8. Institute of Medicine, Committee of Quality
Health Care in America. Crossing the Quality
Chasm: A New Health System for the 21st
Century. Washington, DC: National Academy
Press; 2002.
9. Fassett W. Patient Safety and Quality
Improvement Act of 2005. Ann Pharmacother.
2006;40(5):917-924.
10. Cutler DM, Feldman NE and Horwitz JR. U.S.
adoption of computerized physician order entry
systems. Health Affairs. 2005;24:1654-1663.
11. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical records systems transform health
care? Potential health benefits, savings, and costs.
Health Affairs. 2005;24:1103-1117.
12. Roukema J, Renske KL, Bleeker SE, et al. Paper
versus computer: feasibility of an electronic medical record in general pediatrics. Pediatrics.
2006;117:15-21.
13. Huvane K. Common Mistakes Practices Make
When Implementing an EMR. Available at:
www.mdng.com. Accessed August 2006. ■
JOURNAL WATCH: JSLS
Assessing the Learning Curve for Laparoscopic
Supracervical Hysterectomy. Ghomi A et al.
2007;11:190-194 • This study suggests that the
operating time for laparoscopic supracervical
hysterectomy is significantly reduced after 30
cases. Additionally, it was found that laparoscopic supracervical hysterectomy could be performed
safely during the learning period.
JOURNAL WATCH: General Surgery News
Obesity Care Special Edition. Kagan EB ed. June
2007;34(6 suppl) • From the nature of obesity, to
patient selection and care, to coding and reimbursement, to future treatments, this compendium
of clinical reviews covers the many facets of treating obesity. The supplement even addresses teens
and plastic surgery.
JOURNAL WATCH: Minim Invasive Therapy
Laparoscopic Versus Open Proctocolectomy with
Ileal Pouch-Anal Anastomosis. Zhang H et al.
2007;16(3):187-191 • The authors note that
advances in MIS now allow for the laparoscopic
proctocolectomy with ileal pouch-anal anastomosis and that the literature typically describes
laparoscopic mobilization of the colon but open
protectomy and ileal pouch-anal anastomosis.
Zhang et al used only a small left flank incision to
exteriorize the sample and construct the pouch.
They retrospectively compared one group of 21
patients who underwent laparoscopic proctocolectomy with ileal J-pouch anastomosis to a group of
25 patients who had undergone the open procedure. The authors found that the laparoscopic
approach is technically feasible and provides te
advantages of less blood loss, shorter hospitalization, quicker return of bowel function and better
cosmetic results.
10 laparoscopy today
EXCERPT FROM NEW TEXTBOOK
Prevention and Management of Laparoendoscopic Surgical Complications, 2nd Edition
MANAGEMENT OF INTRAABDOMINAL PELVIC
CATASTROPHES
Raymond J. Lanzafame, MD, MBA
INTRODUCTION
The subject of this chapter is Herculean in scope.
Entire texts have been devoted to this topic.17-22
This chapter will provide an overview of potential perioperative catastrophes and a philosophy
for approaching minimally invasive surgical procedures and their complications.
MANAGING COMPLICATIONS
Although the best method for managing complications is to avoid them, the surgeon must
remain vigilant during laparoscopy to recognize
and address complications immediately. As minimally invasive surgical techniques continue to
develop, it is likely that specialty boundaries will
continue to blur. The surgical laparoscopist
should have a range of skills that permits safe
handling of common complications encountered
during the course of surgery regardless of the
organs involved. By the same token, the surgical
laparoscopist should recognize his or her limitations and request a consultation or the assistance
of a colleague when necessary.
TROCAR AND BOWEL RELATED COMPLICATIONS
Trocar-related complications generally involve
inadvertent laceration or perforation of intraabdominal organs or vascular structures during initial access. The method of gaining access is an
independent variable regarding the incidence of
these problems. The surgeon should choose the
method of access with which she or he is most
comfortable and insert all secondary trocars
under direct vision. The abdomen should be
carefully inspected for serosal injuries or tears
laparoscopy today 11
due to adhesiolysis or traction. Using alternative
puncture sites in patients with abdominal incisions (including previous laparoscopies) will
reduce the possibility of bowel injury during initial puncture.30 A secondary advantage of these
techniques is the ability to perform careful adhesiolysis under direct vision.
Laparoscopic surgery is no different from open
surgery in that significant serosal injuries should
be repaired. Full thickness injuries of the small
bowel can be oversewn with different endoscopic techniques. Repair of small defects can be
accomplished with the use of suture, linear GIA
staplers, or with the use of certain versions of
endoscopic hernia staples. Serosal tears or simple
lacerations are easily repaired with seromuscular
sutures of 3-0 polyglycolic acid or polydioxanone. Extracorporeal or intracorporeal knots
can be used depending on intraoperative findings. Wedge resections of the bowel can be
accomplished and subsequently repaired with
interrupted sutures of 3-0 polyglycolic acid or
polydioxanone. The Endo-GIA can be used with
the triangulation technique to affect an anastomosis and can be applied perpendicularly to the
long axis of the bowel to resect and repair segmental injuries without compromising the diameter of the bowel lumen. Small defects can also be
repaired by careful approximation of the wound
by using Ethicon Endo-hernia staples to close the
seromuscular layer.
Repair of colorectal injuries remains more controversial.33,34 However, the trauma literature4,5,18,33
would argue strongly for primary closures of
minor injuries or lacerations, particularly in
Full text of previous
edition available free
for download
through RSS feed on
www.SLS.org
instances where minimal soiling of the peritoneum has occurred. Any questionable large
bowel injury should be exteriorized or resected,
and sound clinical judgment should prevail as to
whether these injuries should be handled with
open repair, the creation of a proximal colostomy,
or both. Appropriate antibiotic coverage for gramnegative organisms and anaerobic bacteria should
be administered.
GENITOURINARY TRACT INJURIES
to mesenteric division during colectomy. The use
of fiberoptic or other stents has been advocated by
some surgeons in both open and laparoscopic
procedures.20,34,47 Careful placement of surgical
clips and suture ligatures will diminish the risk of
injury. Simple lacerations of the ureter may be
successfully managed with ureteral stenting.
Segmental defects require urologic consultation
and may require ureteroureterostomy or renal
autotransplantation.
RETROPERITONEAL INJURIES
Injuries to the genitourinary system frequently
involve the bladder or ureters.6,20,47 Bladder lacerations may occur with the initial puncture or
pelvic dissection, particularly in cases complicated by dense adhesions or previous radiation therapy. Bladder injuries related to the initial puncture
can be prevented or minimized by routinely using
Foley catheterization or ensuring that the patient
has voided immediately prior to surgery. The
bladder can be instilled with methylene blue or
indigo carmine prior to the initial dissection as a
means of distinguishing it during a complicated
pelvic dissection. Bladder instillation can also be
used after or during the dissection to visualize any
evidence of leak or injury to the bladder because
of surgical trauma. Minor injuries to the bladder
can be handled with catheterization or with bladder closure and drainage. Simple lacerations
should be closed with a single or double layer
using a full thickness suture technique. Most
urologists recommend that chromic suture or
Monocryl (poliglecaprone) be used for urinary
bladder repair because polyglycolic acid and
other materials may act as a nidus for stone formation. Bladder injuries can be devastating if they
are through and through or involve the trigone
area. Cystoscopy may be necessary and should be
considered if any question of such an injury
exists.
Ureteral injuries are best avoided by locating the
ureters prior to division of pelvic vessels or prior
Injury to the retroperitoneum and its structures
can result in significant morbidity or mortality,
particularly if injury to these structures is unrecognized and not properly addressed. Many
retroperitoneal injuries occur due to trocar insertion or traumatic insertion of other instrumentation.38,49,50 The careful placement of trocars and
instruments in a controlled fashion and under
direct vision will prevent the vast majority of
these potentially lethal complications. As with
open surgery, a suspected injury requires careful
and meticulous control. The decision for conversion to an open procedure should be based on
the type and location of the injury. A pelvic
hematoma can be managed initially by packing
or pressure application with fan-type retractors
or the use of vaginal packing or gauze sponges.
An expanding hematoma will require exploration. An apparently stable hematoma should be
observed carefully as the abdomen is desufflated.
Exploration, endoscopic ultrasonography, or
angiography is warranted if the hematoma
expands as the abdominal pressure returns to
baseline. A similar strategy is useful for the management of hematomas at the root of the mesentery and in other areas. Blind suturing and mass
ligature techniques should not be used under any
circumstances. Injuries to the retroperitoneum in
the area of the duodenum or pancreas deserve
particular attention and should always be
explored due to the significant mortality associ-
12 laparoscopy today
scopist conversant with laser technology and its
limitations. Both free-beam and fiberoptic applications are possible. For most surgeons, fiberoptic
ELECTROSURGICAL AND LASER INJURIES
lasers are the simplest to master and apply. The
surgeon should have a thorough understanding of
Injuries may occur from the use of electrosurgical
the particular laser’s wavelength and delivery sysor laser devices during minimally invasive surgi51
tem and carefully consider the depth of penetracal procedures. Many of these injuries can be
tion, tissue effects, and visual appearance of the
prevented by meticulous technique and the caretissue after laser energy has been applied.
ful application of these devices. The minimum
Selection of the appropriate wavelength
amount of energy necessary to coagulate
and delivery system is key to the safe
or cut should be used irrespective of the
The surgical
and successful use of these technologies.
source of that energy. The entire active
laparoscopist
The same basic care as is described for
portion of the electrode or delivery
should have a range
electrosurgical devices should be
instrument should be in clear view prior
of skills that
observed when using lasers. The surto the use of an electrosurgical or laser
permits safe
geon should prevent inadvertent injury
device. The instrument should not be in
handling of common
due to reflected or stray laser energy.
complications
contact with any other structure than
This is accomplished by proper orientaencountered during
the desired target. Electrosurgical device
tion of the device relative to the target,
the course of
injuries may occur as a result of insulasurgery regardless
the use of optical backstops during distion breakage and current leakage, direct
of the organs
section and careful retraction and discoupling as current travels to or from the
involved.
placement of adjacent structures.
electrode to the laparoscope or other
Contact laser devices convert light
instruments, or capacitance coupling
energy
to
heat and as such can cause thermal
because the endoscopic instrument and metallic
injury to adjacent tissues after the laser has been
cannula store energy and function as a capacitor.
disengaged.
Electrical energy may cause isolated tissues or tisated with untreated injuries to the duodenum
and adjacent structures.
sues placed under tension to overheat and secondarily injure adjacent structures as electrical
energy heats tissue with the greatest resistance to
the flow of current to the grounding electrode.
The instrument itself may remain hot for a brief
time after current application, particularly after
protracted use. Contact of adjacent tissues can
produce a thermal burn under these circumstances. Bipolar instruments and the Harmonic
scalpel are also capable of inflicting contact thermal burns to adjacent structures because these
devices also become heated during prolonged
use.
Laser devices of various types have been used for
minimally invasive surgical procedures.52-56 These
tools can be a valuable addition to the surgeon’s
armamentarium when plied by a skilled laparo-
Injuries due to the use of electrosurgical devices,
the Harmonic scalpel, or lasers should be treated
aggressively if noted at the time of surgery.51,52,55
This is particularly important because the visible
appearance of the lesion may grossly underestimate the full extent of injury and subsequent tissue necrosis. Serosal injuries should be oversewn.
Unfortunately, injuries may only be recognized
after tissue necrosis and perforation occur. A high
index of suspicion should be raised in the postoperative patient who presents with severe or
increasing discomfort, fever, or “ileus” after surgery. Prompt assessment and management of
these complications are required in order to avert
significant morbidity or mortality.
BILIARY TRACT INJURIES
Special mention of biliary tract injuries is neces-
laparoscopy today 13
sary. Laparoscopic cholecystectomy brought with
it an increased incidence of injuries to the extrahepatic biliary tree, including segmental defects
considered unique to laparoscopic cholecystectomy.38,57 Although many of these complications
were thought to occur only during the “learning
curve,” any patient who presents with severe
postoperative pain, ileus, or increased discomfort
should be considered to have a bile duct injury or
leak until proven otherwise.57,58,59 Diisopropyl
iminodiacetic acid (DISIDA) scanning and endoscopic retrograde cholangiopancreatography
(ERCP) can elucidate the presence of an injury or
leak. Minor injuries or leaks can be managed with
nasobiliary drainage. However, major injuries
require operative repair. Definitive repair should
be taken early. The surgeon should seek the assistance of surgeons conversant with biliary reconstruction techniques if he or she is not experienced in these techniques.
Way and colleagues57 analyzed the causes and prevention of laparoscopic bile duct injuries based
on their review of 252 cases. They noted that the
primary cause of error was visual perceptual error
in 97% of the cases, with faulty technical skills
accounting for the remaining 3% of injuries.
These authors also found that only 25% of the
injuries were recognized at the initial operation.
More sobering was the fact that only 6% of the
injuries were recognized early enough to limit
further iatrogenic injury. A rather comprehensive
list of rules of thumb is enumerated to help prevent these injuries from occurring.57
LIVER LACERATIONS
Liver lacerations can often be controlled with
gentle pressure and patience.17,22,38 A fan retractor
may be used to compress the parenchyma against
the abdominal wall or back muscles. Hemostatic
agents, such as Surgicel or Avitene, may be quite
useful. Bleeding that persists following 5 to 10
minutes of compressions should be reassessed.36,43
Any specific bleeding point should be dealt with
cautery, argon beam coagulator, laser, hemoclips,
or suture ligation. Packing major injuries with
omentum and drainage of the subhepatic and
subphrenic spaces may be used to control major
problems. However, major injuries should not be
oversewn. The use of vaginal packing or Kerlix
for temporary control of persistent bleeding
from a large injury has its place when bleeding
is ongoing.
INJURY OF FALLOPIAN TUBES,
OVARIES, OR UTERUS
Management of disease or injury to the fallopian
tubes or ovaries should be assessed as to its severity and the likelihood of salvageability. Severe disease or injury will often require resection.56 The
Endo-GIA and similar devices have made resection quite simple. Alternatively, the surgeon can
use Endoloops or hemoclips for serial ligation of
the vascular pedicle and control the fallopian tube
at the level of the infundibulum. Great care must
be taken to avoid iatrogenic injury to the ureters
during dissection. Identification of the ureters
prior to ligation or stapling is important. Minor
injury or bleeding from the ovary can generally be
controlled with compression, cautery, laser photocoagulation, or suture ligation. Simple perforation of the uterus can generally be managed conservatively as has been demonstrated in the literature on dilatation and curettage.9,18,19,21,25,
Contiguous involvement of the uterus with
tumor or disease may require hysterectomy. A
variety of techniques for laparoscopic assisted
vaginal hysterectomy (LAVH) have been
described.9,25 The use of staplers has facilitated
these procedures. Management of the vaginal cuff
will depend on the clinical circumstances.
However, the cuff may be oversewn with polyglycolic acid or chromic sutures or stapled with titanium or absorbable staples. To facilitate removal,
the large uterus can be sectioned or morcellated
and delivered vaginally or through a mini-laparotomy incision.
14 laparoscopy today
CONCLUSION
Knowledge of anatomy and strict attention to
detail will prevent many complications. However,
it must be recognized that anatomic conditions in
vivo are rarely as depicted in textbooks. The keys
to management of catastrophic or minor complications are careful, methodical assessment and
appropriate action without panic. The surgeon
should feel comfortable in converting an MIS procedure to an open one when necessary and
should endeavor to cooperate with colleagues in
the best interest of the patient.
References
4. Arregui ME, Fitzgibbons RJ, Katkhouda N,
McKernan JB, Reich H, eds. Principles of
Laparoscopic Surgery: Basic and Advanced
Techniques. New York, NY: Springer Verlag; 1995.
5. Ballantyne GH, Leahy PF, Modlin IM. Laparoscopic
Surgery. Philadelphia, PA: WB Saunders Co; 1994.
6. Das S, Grawford ED. Urologic Laparoscopy.
Philadelphia, PA: WB Saunders Co; 1994.
9. Luciano AA, Maier DB, Marana R. The role of opera
tive gynecological endoscopy today. Contrib Gynecol
Obstet. 1991;18:33-41.
17. Crist DW, Gadacz TR. Complications of laparoscopic
surgery. Surg Clin North Am. 1993;73(2):265-289.
18. Lanzafame RJ, ed. Prevention and Management of
Complications in Minimally Invasive Surgery. New
York, NY: Igaku-Shoin; 1996:368.
19. Nord HJ. Complications of laparoscopy. Endoscopy.
1992;24(8):693-700.
20. Parra RO, Hagood PG, Bouiller JA, Cummings JM,
Mehan DJ. Complications of laparoscopic urological
surgery: experience at St. Louis University. Urology.
1994;151(3):681-684.
21. Ponsky JL. Complications of Endoscopic and
Laparoscopic Surgery Prevention and Management.
Philadelphia, PA: Lippincott-Raven; 1997:292.
22. Wolf JS Jr, Stoller ML. The physiology of
laparoscopy: basic principles, complications and
other consideration. J Urol. 1994;152 (2 pt 1):294302.
30. Sadeghi-Nejad H, Kavoussi LR, Peters CA. Bowel
injury in open technique laparoscopic cannula
placement. Urology. 1994;43(4):559-560.
33. Nezhat C. Nezhat F, Ambroze W, Pennington E.
Laparoscopic repair of small bowel and colon. A
report of 26 cases. Surg Endosc. 1993:7(2):88-89.
34. Hoffman GC, Baker JW, Fitchett CW, Vansant JH.
Laparoscopic-assisted colectomy. Initial experience.
Ann Surg. 1994;219(6):732-743.
36. Azzis R, Murphy AA, Rosenberg SM, Patton GW Jr
Use of an oxidized, regenerated cellulose absorbable
laparoscopy today 15
Raymond J. Lanzafame, MD, MBA, a past president of
the Society of Laparoendoscopic Surgeons, is Editor-inChief of Photomedicine and Laser Surgery and sits on
the editorial boards of General Surgery News; Journal of
Laparoendoscopic Surgery; JSLS, Journal of the Society
of Laparoendoscopic Surgeons; Lasers in Surgery and
Medicine; and Lasers in Medical Science. He is a past
president of the Upstate Chapter of the American
College of Surgeons and the American Society for Laser
Medicine and Surgery (ASLMS). Dr Lanzafame has testified before the FDA on device regulation; participates
in national panels on lasers, credentialing, laparoscopy,
and managed care; and performs medicolegal and
biotech consulting. He is consultant to the General and
Plastic Surgery Devices and Medical Devices Advisory
Committee panels of FDA-CDRH. He holds 27 organizational memberships, and his publications include
numerous papers and textbooks.
adhesion barrier at laparoscopy. J Reprod Med.
1991;36(7):479-482.
47. Grainger DA, Soderstrom RM, Schiff SF, Glickman
MD, DeCherney AH, Diamond MP. Ureteral injuries
at laparoscopy: insights into diagnosis management,
and presentation. Obstet Gynecol. 1990;75:839-843.
48. Nordestgaard AG, Bodily KC, Osborn RW Jr, Buttorff
JD. Major vascular injuries during laparoscopic
procedures. Am J Surg. 1995;169(5):543-545.
49. Wolf JS Jr, Carrier S, Stoller ML. Intraperitoneal versus extraperitoneal insufflation of carbon dioxide as
for laparoscopy. J Endourol. 1995;9(1):63-66.
50. Wolf JR Jr, Clayman RV, Monk TG, McClennan BL,
McDougall EM. Carbon dioxide absorption during
laparoscopic pelvic operation. J Am Coll Surg.
1995;180(5):555-560.
51. Soderstrom RM. Electrosurgical injuries during
laparoscopy: prevention and management. Curr
Opin Obstet. 1994;6(3):248-250.
52. Lanzafame RJ. Laser Utilization in minimally invasive surgery: Applications and pitfalls. In: Lanzafame
RJ, ed. Prevention and Management of
Complications in Minimally Invasive Surgery. New
York, NY: Igaku-Shoin; 1996:9930-9943.
53. Lanzafame RJ. Applications of lasers in laparoscopic
cholecystectomy. J Laparoendosc Surg.
1990;1(1):33-36.
54. Lanzafame RJ. Applications of laser in laparoscopic
cholecystectomy: technical considerations and future
directions. SPIE. 1991;1421:189-196.
55. Hunter JG. Exposure, dissection, and laser versus
electrosurgery in laparoscopic cholecystectomy. Am J
Surg. 1993;165(4):492-496.
56. Laycock WS, Hunter JG. Electrosurgery and laser
application. In: MacFayden BV, Ponsky JL, eds.
Operative Laparoscopy and Thoracoscopy.
Philadelphia, PA: Lippincott-Raven; 1996:79-91.
57. Way LW, Stewart L, Gantert W, et al. Causes and pre
vention of laparoscopic bile duct injuries. Analysis of
252 cases from a human factors and cognitive psy
chology perspective. Ann Surg. 2003;237(4):460-469. ■
PICK FROM
JSLS, Journal of the Society of Laparoendoscopic Surgeons
Hernias as a Cause of Chronic
Pelvic Pain in Women
C. Paul Perry, MD, Juan Diego Villegas Echeverri, MD
INTRODUCTION
Inguinal, abdominal, and pelvic floor fascial defects
cause pain in many patients, male and female. Pain
patterns are very specific to the location and hernia
type. However, women are subject to delayed diagnosis and treatment because they may present to
their gynecologists with chronic pelvic pain due to
a condition formerly relegated to the discipline of
general surgery. Physicians treating chronic pelvic
pain patients should be knowledgeable in the diagnosis and surgical treatment of these women.
A hernia is an abnormal opening or defect through
which organs or tissue may protrude. The actual
mechanism by which these defects produce pain is
debatable. Incarceration and ischemia notwithstanding, the majority of painful hernias produce
pain by mechanical distortion transduced into an
electrochemical impulse transmitted by peripheral
nerves to the central nervous system where it is
perceived.1 Symptoms produced by hernias are
usually aching, sharp, shooting, and radiating. The
location of the pain is specific for the location of the
hernial defect and its neuralgia. Not all hernias are
symptomatic. In one study, 4 of 54 (7%) inguinal
hernias in women diagnosed laparoscopically were
producing no symptoms.2
Hernias are classified by anatomical location: ventral, inguinal, and pelvic floor. Ventral hernias can
be either spontaneous or incisional. Midline, epigastric, and umbilical hernias are usually easy to
detect. A Spigelian hernia is congenital and occurs
at the lateral border of the rectus abdominis muscle
and just below the semilunar line of the posterior
rectus fascia. Pain and tenderness over the area may
be accompanied by a palpable mass. Patients with
symptomatic ventral hernias complain of
sharp intermittent pain aggravated by
activity and decreased by lying down. The
tenderness on examination is exacerbated
by having the patient raise her head. An
incisional hernia is usually due to midline
incisions, but may be due to a Pfannenstiel.
Diagnosis of these transverse incisional
hernias may be more difficult. Ilioinguinal
neuralgia from entrapment will produce a
similar history and physical findings.3
Search 11 years of
JSLS and access
Inguinal hernias are much more difficult to hundreds of free pdf
diagnose in women than in men. It is typi- downloads through
cal for women to have nonpalpable or www.SLS.org
occult inguinal hernias. These can only be adequately evaluated laparoscopically.4,5 Diagnosis is
suspected by pain distribution and tenderness over
the internal ring. Symptoms include pain in the
lower abdomen or groin when lifting, coughing,
and sneezing with radiation into the labia majora
and anterior thigh. The neurological nociceptors
include the genital branch of the genitofemoral
nerve, the ilioinguinal nerve, the femoral nerve, or
all of these. Patients may have indirect, direct,
femoral, or a combination of any of these three.
Indirect inguinal hernia is the most common hernia in women. It is congenital and due to nonclosure of the processus vaginalis. Tissue protrudes
through the internal ring and passes down the
inguinal canal a variable distance with the round
ligament. Direct inguinal hernia is acquired and is
the second most common inguinal hernia in
women. Femoral hernias occur more commonly in
women than in men. They are produced by a protrusion of preperitoneal fat or viscus through a
weak transversalis fascia and into the femoral ring
16
laparoscopy today
and the femoral canal.6
Pelvic floor hernias include sciatic, obturator, paravesical, and perineal. All pelvic floor hernias are
more common in women due to the broader pelvic
inlet and the stresses of pregnancy, labor, and delivery. Sciatic hernias result from the protrusion of a
peritoneal sac through the greater or lesser sciatic
foramen. These patients will have typical sciatica
with a negative MRI for disk herniation. Findings
at laparoscopy are a sac in the lateral pelvis that
deviates the ureter medially toward or onto the
uterosacral ligament. Ovarian incarceration can
occur in these defects.7
obstruction. A small proportion of patients may
present only with chronic pelvic pain and innerthigh neuralgia. Diagnosis is made by vaginally palpating the obturator foramen reproducing the
symptoms as a result of compression of the obturator nerve in its tunnel (Howship-Romberg sign).6
A paravesical hernia may pass through the
supravesical fossa of the anterior abdominal wall or
into spaces around the urinary bladder. Increased
lower pelvic pressure may be the only symptom.
These hernias are easily diagnosed laparoscopically.6
Perineal hernias are extremely rare and can be
Obturator hernia results from a protrusion of
either anterior or posterior to the superficial transpreperitoneal fat or an intestinal loop
verse perineal muscle. They can be
...women are
through the obturator foramen alongspontaneous
or
occur
after
6
subject to delayed
side the obturator vessels and nerve. It is
abdominoperineal resection.
diagnosis and
considered rare (0.07% of all hernias),
The treatment of chronic pelvic pain due
treatment because
but it may be the most common in the
to hernias is surgical. It can be perthey may present to
pelvic floor. These patients present with
formed by open or laparoscopic techtheir gynecologists
pain in their lower pelvis and inner
niques. The laparoscopic approach is
with chronic pelvic
thigh, which radiates into the hip and
either transabdominal or extraperipain due to a
behind their knee. Pain increases when
toneal. We strongly favor the laparocondition formerly
standing, lifting, and crossing the legs.
scopic approach due to its minimally
relegated to the
Three types of obturator hernias are
invasive nature and its diagnostic capadiscipline of
described based on the anatomical
bilities. For most patients with chronic
general surgery.
defect that is present. Type I occurs
pelvic pain, surgical trauma increases
when preperitoneal fat and connective
spinal cord upregulation and potentiates
tissue (pilot tag) enter the pelvic orifice
their associated neuropathies and reflex myalgias.
of the canal. Type II causes dimpling of the periMany patients will have multiple pain generators
toneum over the canal leading to the formation of
and the transabdominal approach allows concomian empty peritoneal sac. Type III occurs on the
tant diagnosis and surgical management. However,
entrance of an organ (bowel, ovary, or bladder) that
the technical ease and improved visibility of the
eventually fails to reduce spontaneously. A partial
extraperitoneal access to the obturator space makes
or complete small bowel obstruction has historicalthis technique preferable for obturator hernia
ly been responsible for the diagnosis of most obturepairs.
rator hernias (88%). The incidence of these hernias
is significantly higher in females (6:1) and may be
Recently, our preference for laparoscopic treatment
due to their larger foraminal diameter. Bowel
of inguinal hernias in women has been challenged
obstructions from obturator hernias are usually in
by a large randomized, controlled study in male
elderly (average age 70), thin patients. With the
patients.8 By comparing recurrence and complicaadvent of CT and MRI, diagnosis of these type III
tion rates in open and laparoscopic repairs, the
hernias may occur before the onset of bowel
conclusion was that the open technique gives supe-
laparoscopy today 17
rior results. The study did emphasize that the
results are experience dependent. After a surgeon
had performed a large number laparoscopically,
there was no significant difference in recurrences or
complications.
An issue not addressed by this study was the difference in patients with acute pain versus chronic
pain. Chronic pain causes complex neuroplasticity,
centralization, and neuroupregulation that may not
be seen in the usual hernia patient. Most of our
patients have multiple visceral pain generators in
addition to hernias. These include endometriosis or
ovarian and tubal pathologies, which require treatment along with their hernias. Therefore, this allmale study may have limited value for those who
treat chronic pelvic pain in women.
To test our hypothesis that hernia pain could be
effectively treated by laparoscopic repair in women
with chronic pelvic pain, we undertook this retrospective study. An attempt was made to identify all
pain generators preoperatively, visceral and somatic, and to specifically evaluate the surgical treatment outcomes based on that portion of the
patient’s symptoms produced by the hernial defect.
Alleviation of site-specific groin, sciatic, abdominal,
and obturator pain was the end point for successful
surgical treatment. Relief of concurrent dysmenorrhea, dyspareunia, pelvic floor tension myalgia,
irritable bowel syndrome, vulvar vestibulitis,
painful bladder, iliopsoas and quadratus lumborum
muscle spasm, trigger points and a host of other
pathologies were evaluated and treated independently as indicated.
METHODS
Our patient population comes from a referral-based
practice dedicated to the diagnosis and treatment of
chronic pelvic pain in women. All patients completed an extensive pelvic pain questionnaire
designed to detect multiple pain generators both
visceral and somatic. This instrument is available at
the International Pelvic Pain Society website,
www.pelvicpain.org. All previous operative reports
were obtained and reviewed.
A detailed, pain-focused, physical examination was
conducted including a careful search for hernial
defects, which might be suspected from the
patient’s history. Lower pelvic pain complaints were
investigated by careful palpation of the internal
rings for tenderness and impulse both lying and
standing. Pain in the pelvis and medial thigh with
referral to the hip and posterior knee had palpation
of the obturator canals. Palpation of abdominal
scars with and without head raising was routine.
Sciatic hernias were suspected by the patient’s complaints of buttock pain referred down the posterior
thigh in the absence of herniated disks.
Laparoscopic repairs were performed by the transabdominal preperitoneal technique, except for
obturator hernias, which were done entirely
extraperitoneally. Standard tension-free mesh techniques were used in all cases. All repairs were performed by the primary author. All 16 obturator hernia patients underwent bilateral repair. This was
due to the high incidence of contralateral recurrence and the fibrosis from the initial repair limiting future access to the retropubic space in these
patients.
RESULTS
From January 13, 1999, through December 17,
2003, 386 hernial defects were repaired by the primary author on 264 patients referred to a chronic
Hernias by Type and Complications
Hernia Type
Right
Side
Left
Side
Bilateral
No. of
Hernias
Indirect Inguinal
142
84
62
226
Direct Inguinal
32
22
10
54
Femoral
22
8
6
30
Sciatic
26
7
6
33
32‡
16
Obturator
Paravesical
1
Umbilical
9
9
Incisional
17
17
Complications
3*
1†
1
1§
table 1
*One patient with persistent neuropathic pain from left inguinal hernia repair; one
patient with postoperative bleeding managed conservatively; one patient with postoperative urinary retention from blood clot in catheter.
†Vaginotomy with repair.
‡ All obturator hernias were bilateral repairs.
§One cystotomy with repair.
18 laparoscopy today
pelvic pain clinic. There have been no recurrences.
Surgical results were excellent and complications
were rare. Length of follow-up is 1.53 years (range,
2 months to 5.5 years). One patient (0.4%) with an
inguinal hernia had persistent inguinal pain from
an ilioinguinal neuropathy, and all other complications resulted from concomitant surgeries.
Symptoms referable to their hernias resolved in 263
patients (99.6%). Other laparoscopic surgeries
were performed at the same time as hernia repairs
in 235 (90%) patients. Laparoscopic hysterectomy,
excision of endometriosis, lysis of adhesions, uterine suspension, presacral neurectomy, and other
procedures all had separate, but well-defined,
potential pain relief benefits. Pain relief from the
specific repaired hernial defects was easily discriminated. The pain produced by the hernia was the
only symptom evaluated in this study. Four
patients experienced complications from concomitant surgeries (1.5%) (Table 1).
Postoperatively, patients with persistent nonhernial
pain (dyspareunia, dysmenorrhea, muscle spasms,
and others) were treated in the recommended multidisciplinary fashion. Many continue to be followed in our clinic with the necessary pharmacological, physical, therapeutical, and psychological
support. Their treatment is tailored to accomplish
maximal reproductive and sexual function with
minimal pain. While the percentage of patients
requiring continued care was not calculated, all
References
1. Fields HL. Pain. NewYork: McGraw Hill; 1987;27.
2. Watson DS, Sharp KW, Vasquez JM, Richards WO.
Incidence of inguinal hernias diagnosed during
laparoscopy. South Med J. 1994;87:23–25.
3. Perry CP. Peripheral neuropathies and pelvic pain:
diagnosis and management. Clin Obstet Gynecol.
2003;46(4):789 –796.
4. Spangen L, Andersson R, Ohlsson L. Non-palpable
inguinal hernia in the female. Am Surgeon.
1998;9:574 –577.
5. Kavic MS. Chronic pelvic pain, hernias and the gen-
laparoscopy today 19
were more easily managed after surgical treatment
and resolution of their hernia-generated pain components.
CONCLUSION
Hernias are responsible for chronic pelvic pain in
some women. To obtain symptomatic relief, this
diagnosis must not be missed by clinicians treating
women with chronic pelvic pain. Hernias should be
suspected by a thorough history and physical
examination. They can be confirmed and treated
laparoscopically along with other concomitant visceral pathologies. Laparoscopic treatment of these
fascial defects has a low recurrence and complication rate in the hands of an experienced laparoscopist.
Reprinted from JSLS, Journal of the Society of
Laparoendoscopic Surgeons. 2006;10(2):212–215.
Correspondence: C. Paul Perry, MD, Department of
Obstetrics and Gynecology, University of Alabama at
Birmingham, 2006 Brookwood Medical Center Dr,
Birmingham, AL 35209, USA. Telephone: 205 397 9000,
Fax: 205 397 9001
C. Paul Perry, MD, is Director of the C. Paul Perry Pelvic
Pain Center at Brookwood Women’s Medical Center in
the Department of Obstetrics and Gynecology at the
University of Alabama at Birmingham.
Juan Diego Villegas Echeverri, MD, is in the Endoscopic
Gynecology section of the Ob/Gyn department of
Colegio Mayor de Nuestra Senora del Rosario and is
with the Center of Specialists of Risaralda, Colombia.
eral surgeon. J Laparoendosc Surg. 1999;3:89–90.
6. Carter JE. Hernias. In: Pelvic Pain: Diagnosis and
Management. Howard FM, Perry CP, Carter JE, ElMinawi AM, eds. Philadelphia, PA: Lippincott
Williams & Wilkins; 2000;383–423.
7. Miklos JR, O’Reilly MJ, Saye WB. Sciatic hernia as a
cause of chronic pelvic pain. Obstet Gynecol.
1998;91:998 –1001.
8. Neumayer L, Giobbie-Hurder A, Jonasson O, et
al. Open mesh versus laparoscopic mesh repair of
inguinal hernia. N Engl J Med. 2004;350:1819
–1827. ■
PICK FROM
JSLS, Journal of the Society of Laparoendoscopic Surgeons
Endoscopic Transaxillary Near Total
Thyroidectomy
Titus D. Duncan, MD, Ijeoma Acholonu Ejeh, MD, Fredne Speights, MD, Qammar N. Rashid, MD, Mustafa Ideis, BS
INTRODUCTION
Endoscopic thyroidectomy has joined the ranks of
surgical procedures being performed via a minimally invasive approach. Since its first reported
performance in 1996, cervical minimally invasive
procedures have been deemed safe and effective
for treating benign thyroid and parathyroid disease.1 Endoscopic approach to the thyroid and
parathyroid gland may be performed through a
direct or indirect (remote) technique. The direct
approach places the access ports within the cervical region and is considered the least invasive.2–5
The indirect approach provides access to the neck
through a remote site from the target area.6 –11
Though this approach provides superior cosmesis,
it is the most invasive, requiring a relatively large
working space to access the thyroid region.
Of the indirect procedures, the transaxillary technique approaches the gland from a remote lateral
site to completely hide the surgical scars. Because
this is a lateral approach, its primary application
has historically been treatment of unilateral thyroid and parathyroid disease.9 In this study, we
examined the safety and feasibility of the transaxillary technique to dissect and remove both sides
of the thyroid gland in performing a total or near
total thyroidectomy for benign thyroid disease.
METHODS
From August 2003 to August 2005, we successfully performed endoscopic transaxillary thyroid and
parathyroidectomy surgery for unilateral and
parathyroid disease in 41 patients. In this study,
we set out to explore the feasibility of an endoscopic transaxillary approach in performing near
total to total thyroidectomy for benign thyroid disease. Before performing this technique in humans,
technical and safety data confirming its feasibility were obtained in animal and human
cadaver models. The challenge of this
approach was the ability to visualize and
safely dissect the contralateral lobe while
adequately identifying and avoiding injury
to the recurrent laryngeal nerve (RLN) and
parathyroid glands.
In this study, 3 human cadaver models were
initially used to validate the technical feasiSearch 11 years of
bility. Following affirmation of the technical
JSLS and access
feasibility of the procedure, we used the anihundreds of free pdf
mal (pig) model for live tissue study before
downloads through
attempting it on a human patient. Technical
www.SLS.org
feasibility was arbitrarily defined as the ability to adequately visualize the target gland and its
adjacent vital structures (i.e., RLN, parathyroid
glands, carotid artery, jugular vein, and others),
the ability to safely dissect and mobilize, and the
ability to complete the procedure within a time
period commensurate with a learning curve
model.
Cadaver Model Operative Technique
Three 5-mm incisions were made in the anterior
axillary line beneath the pectoralis major muscle.
Using two 2-mm Steinman pins, blunt dissection
beneath the platysma and superior to the pectoralis major muscle was performed to develop the
initial working space. The working space was
insufflated with CO2 insufflation of 10 mm Hg,
and dissection of the connective tissue continued
with the Harmonic scalpel and scissor cautery. The
sternocleidomastoid muscle was identified, and
the plane between the sternocleidomastoid and
the sternohyoid muscle was dissected. After elevating the sternohyoid muscle, the sternothyroid
muscle was visualized and retracted anteriorly
exposing the ipsilateral thyroid gland. The inferior
20
laparoscopy today
Pig Model Operative Technique
Figure 1. Lateral view of transaxillary approach.
pedicle was bluntly dissected while the RLN was
identified. The vessels were then clipped and
divided. Smaller vessels were divided by using the
Harmonic scalpel (Ethicon Endo-Surgery,
Cincinnati, OH) exposing the ligament of Berry.
This ligament was divided to mobilize the gland
and to allow exposure of the superior thyroid
pedicle. The superior thyroid vessels were dissected, clipped, and divided from within the capsule
of the gland. Dissection of the gland completely
from the anterior trachea facilitated retraction of
the gland medially exposing the contralateral
side. Under direct visualization, the vessels of the
contralateral inferior pole were dissected near the
thyroid capsule, ligated, and divided. This maneuver allowed further medial and cephalad retraction of the thyroid gland. Using the 45-degree 5mm endoscope, the contralateral RLN was identified. On the second cadaver, the nerve could not
be adequately identified until the trocar housing
the 5-mm 45-degree scope was placed medial to
the anterior axillary line (Figure 1) on to the anterior chest wall location to thoroughly inspect the
contralateral
tracheoesophageal
groove.
Subsequently, the nerve and parathyroid glands
were visualized by using this additional maneuver. After nerve and parathyroid identification,
the Harmonic scalpel was used to dissect and
transect the remainder of the thyroid gland up to
the contralateral superior pole. Due to some difficulty exposing this portion of the gland, division
of the sternothyroid muscle was necessary. After
division of the superior pole, the total gland was
extracted through an extended axillary incision.
laparoscopy today 21
The operative procedure was performed with the
pig under general anesthesia. After positioning
the animal to extend the neck, three 5-mm trocars
were placed along the lateral chest wall near the
axilla. Dissection along the anterior chest wall
directed toward the animal’s cervical region was
accomplished using the Harmonic scalpel. The
sternocleidomastoid muscle and the thyroid
gland were identified in the fashion previously
described.13 After dissection of the ipsilateral
gland, the opposite lobe was explored. The isthmus of the gland was grasped and dissected, freeing the posterior gland from the anterior surface
of the trachea. Using gentle traction on the gland,
the contralateral inferior lobe was retracted superiorly exposing the inferior vascular pedicle as it
penetrated into the thyroid gland. Gentle dissection of the surrounding areolar tissue isolated the
vessels that were clipped and divided. This
increased the mobility of the gland and allowed
further retraction of the gland superiorly and
medially. The recurrent laryngeal nerve was now
easily appreciated with the 5-mm 45-degree endoscope. Staying within the capsule of the gland,
dissection of the middle thyroid vein was accomplished. The 5-mm Harmonic scalpel was used to
dissect, clip, and divide smaller vessels to the thyroid. This maneuver allowed complete mobility of
the gland exposing the superior thyroid pedicle.
The superior vessels were then clipped and divided freeing the entire gland, all the while protecting the recurrent laryngeal nerve. The gland was
removed through an extended lateral incision.
Human Patient Operative Technique
After IRB approval and informed patient consent,
3 female patients were selected for endoscopic
near total thyroidectomy each with a history of
enlarging multinodular goiter.2 All 3 patients had
been followed on an average of 7 years (range, 4
to 19) with a history of a gradual increase in size
of the gland before consideration for surgical
extirpation. Average age in this group was 31
years (range, 18 to 61). Fine needle aspiration was
Figure 2. Positioning of the patient for near total thyroidectomy.
Figure 3. Dissection area using transaxillary approach.
performed in all patients. Preoperatively, no clinical or pathological evidence of malignancy was
present.
The patient was placed on the operating table and
general anesthesia was administered. The patient’s
arm was abducted at 90 degrees to the vertical
axis of the body to expose the axilla (Figure 2).
Three 5-mm incisions were made, and initial dissection of the working space was accomplished
with blunt 3-mm Steinman pins beneath the
platysma and anterior to the pectoralis major
muscle. Three 5-mm trocars were placed through
the incisions and directed towards the thyroid
gland (Figure 3). Insufflation of CO2 at an initial
pressure of 7 mm Hg pressure was used to maintain the working space. Dissection was then carried out to reach the sternocleidomastoid muscle
and thyroid gland.
The ipsilateral thyroid lobe was identified and
mobilized. After mobilization of the isthmus from
the anterior surface of the trachea, the gland was
grasped and gently retracted anteromedially. This
maneuver was facilitated by division of the sternothyroid muscle leaving the more superficial
sternohyoid muscle intact. This allowed greater
anterior retraction, exposing the contralateral
inferior thyroid pole. Complete dissection of the
junction between the thyroid capsule and the
contralateral inferior thyroid vessels was accomplished. These vessels were then clipped and
divided. Complete mobility of the gland was
accomplished, and the contralateral superior thyroid pedicle was exposed (Figure 4). The superior vessels were then clipped and divided, freeing
Figure 4. Identification of recurrent laryngeal nerve and
parathyroid gland.
the entire gland while protecting the recurrent
laryngeal nerve. The gland, completely detached,
was placed in an Endocatch (Ethicon EndoSurgery, Cincinnati, OH) retrieval bag and
removed through an extended lateral incision
within the axilla. The paratracheal spaces were
inspected for hemostasis. A 7-mm Blake drain was
placed within the thyroid bed and anterior chest
wall, and brought out through one of the 5-mm
axillary port sites (Figure 5).
RESULTS
Before initiating the present study, we successfully
completed 32 unilateral thyroidectomy proce-
Figure 5. Postoperative day 2 with drain.
22
laparoscopy today
dures for benign thyroid disease by using an
endoscopic transaxillary approach. The operative
time for these procedures averaged 142 minutes
(range, 57 to 327) and has remained relatively stable over the last 15 cases.
In the cadaver and pig models, optimal magnified
visualization was achieved using the endoscopic
approach.4 Although identification of the thyroid
gland and adjacent vital structures was easier in
the porcine model, the cadaver model more accurately represented the anatomy as seen in live
patients. Dissection of the ipsilateral and contralateral thyroid lobes was accomplished with
good visualization of the RLN and parathyroid
glands. Combined operating times in both models
averaged 112 minutes (range, 109 to 327).
Following successful completion of total thyroidectomy using cadaver and live animal models,
we proceeded to evaluate safety and efficacy in
humans. In this clinical study, 3 live human subjects presented with a diffusely enlarged multinodular goiter that had clinically increased in size
over the past year. All 3 patients had unilateral
lobe sizes of 4 cm or less as determined by preoperative thyroid ultrasonography. Fine needle aspiration revealed benign colloid cells in all 3 individuals.
Upon operative dissection, as described above, we
were successful at visualization of the ipsilateral
thyroid gland in all models. Further dissection
allowed clear visualization of the contralateral
lobe and its adjacent major structures. The recurrent laryngeal nerve and parathyroid glands were
clearly identified. The operative time for these
patients averaged 128 minutes (range, 99 to 195)
(Table 1). The axillary incision had to be extended to an average 35 mm (range, 18 to 49) to adeOperative Time (Minutes)
Model
One (min)
Two (min) Three (min)
Mean
Operative
Time
Porcine
91
102
83
92
Cadaver
135
115
146
132
Human
195
90
99
128
table 1
laparoscopy today 23
Figure 6. Postoperative day 14 with drain removed.
quately extract the thyroid specimen. All incisions
were covered with the subject’s arm in the normal
anatomic position (Figure 6). There were no
injuries to the recurrent laryngeal nerve or
parathyroid glands.3 Dissection in a parallel plane
to the anterior axillary line and above the pectoralis major muscle avoided injury to other
structures within the axilla, including the long
thoracic, thoracodorsal, and brachial plexus
nerves. There were no postoperative complications, such as bleeding or hoarseness, and no
adverse sequelae of CO2 insufflation. There were
no postoperative complaints of dysphagia or stridor. All patients were discharged on postoperative
day 2, and all drains were removed within 72
hours of surgery.
DISCUSSION
Endoscopic thyroidectomy provides a minimally
invasive approach to the thyroid gland, resulting
in improved visualization of anatomic structures
for the surgeon and superior cosmetic results for
the patient. The most commonly performed
endoscopic approach places the trocars anteriorly
within the neck region to directly access the thyroid.12 Though this direct approach has been
shown to be the least invasive, the cosmetic
results may prove less than optimal in patients
with large thyroid lesions that require extension
of the neck incision for extraction. Furthermore,
if it becomes unsafe to proceed endoscopically
using the direct approach (bleeding, poor visualization, and other complications), conversion to
superior visualization of local anatomy and
improved cosmesis. Most endoscopic techniques
that approach the gland from the anterior neck or
chest surface limit the size of gland that can be
removed to avoid unsatisfactory cosmetic results.
The endoscopic transaxillary approach conceals
A significant percentage of patients presenting
the incisions within the axilla, allowing removal
with thyroid disorders will harbor multifocal disof larger lesions without compromising cosmesis.
ease that may require total or near total
The remote transaxillary technique
thyroidectomy.7 To date, this approach
we set out to
provides access to the thyroid gland by
has not been studied for malignant dissubcutaneously traversing the chest
explore the
ease of the thyroid gland and is therewall via a lateral videoscopic approach
feasibility of
fore not recommended.
avoiding any incision in the cervical
an endoscopic
In our study, visualization of the recurarea. Because of the amount of tissue
transaxillary
rent laryngeal nerve and parathyroid
dissected to reach the target area, this
approach in
glands was clear, detailed, and without
procedure is the most invasive of the
performing near
doubt. For an endoscopic approach to
minimal access techniques to the thytotal to total
be a viable alternative to open surgery,
roid gland. Such an approach minithyroidectomy….
it should be a feasible approach for a
mizes any perceived cosmetic deformimajority of surgical diseases involving
ty and possible anxiety concerning the
the thyroid gland. This study shows that endocosmetic outcome of the surgery.6 Because there
scopic transaxillary thyroidectomy is safe and feais no difference in hospital stay between this prosible in select patients with multifocal and bilatercedure and the direct cervical approach, and
al thyroid disease. For select patients with
because postoperative pain may be increased with
multinodular goiters transaxillary thyroidectothis maximally invasive technique, better cosmemy a useful and cosmetically superior alternasis and possibly safer dissection through
tive to open thyroidectomy.
improved visualization may be the only perceived
the open approach would result in several visible
neck incisions in addition to the open cervical
incision, giving an unsatisfactory cosmetic outcome.
benefits of this particular approach. Although the
endoscope provides excellent visualization and
magnification, the unconventional approach from
the lateral fields requires thorough knowledge of
the anatomy in this area. This technique has been
previously described for benign unilateral thyroid
disease with safety and excellent cosmetic
results.9,11 Although the transaxillary approach has
been deemed safe and effective in patients with
unilateral disease, its application in bilateral disease has not been explored. Possibly inadequate
visualization of the contralateral anatomy, resulting in inadequate and precarious dissection, may
be the reason.
Reprinted from JSLS, Journal of the Society of
Laparoendoscopic Surgeons. 2006;10(2):206 –211.
Correspondence: Titus D. Duncan, MD, C/O Peachtree
Surgical & Bariatrics, 300 Blvd NE, Atlanta, GA 30309,
USA. Telephone: 404 881 8020, Fax: 678 553 3179, Email: [email protected]
Titus D. Duncan, MD, is affiliated with Morehouse
School of Medicine, Atlanta Medical Center. He s an
active member of SLS and serves on the JSLS editorial
board.
Ijeoma Acholonu Ejeh, MD, is affiliated with
Morehouse School of Medicine, Atlanta Medical Center.
Fredne Speights, MD, is affiliated with Morehouse
School of Medicine, Atlanta Medical Center.
CONCLUSION
Although endoscopic thyroid surgery has been
shown to be safe and effective, its use remains
limited. Advantages of this technique include
Qammar N. Rashid, MD, is affiliated with Morehouse
School of Medicine, Atlanta Medical Center.
Mustafa Ideis, MD, is affiliated with Morehouse School
of Medicine, Atlanta Medical Center.
(continued on page 25)
24 laparoscopy today
(continued from page 24) References: Endoscopic Transaxillary Near Total Thyroidectomy
References
1. Gagner M. Endoscopic subtotal parathyroidectomy in
patients with primary hyperparathyroidism. Br J Surg.
1996;83(6): 875.
2. Inabnet WB, Chu CA. Transcervical endoscopicassisted mediastinal parathyroidectomy with intraoperative parathyroid hormone monitoring. Surg
Endosc. 2003;17(10):1678.
3. Miccoli P, Bendinelli C, Conte M, et al. Endoscopic
parathyroidectomy by a gasless approach. J
Laparoendosc Adv Surg Tech A. 1998;8(4):189 –194.
4. Miccoli P, Bendinelli C, Vignali E, et al. Endoscopic
parathyroidectomy: report of an initial experience.
Surgery. 1998;124(6): 1077–1079.
5. Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT.
Endoscopic endocrine surgery in the neck. An initial
report of endoscopic subtotal parathyroidectomy.
Surg Endosc. 1998;12(3): 202–205.
6. Ng WT. Scarless endoscopic thyroidectomy: breast
approach for better cosmesis. Surg Laparosc Endosc
Percutan Tech. 2000; 10(5):339 –340.
7. Ohgami M, Ishii S, Arisawa Y, et al. Scarless endoscopic thyroidectomy: breast approach for better
cosmesis. Surg Laparosc Endosc Percutan Tech.
2000;10(1):1– 4.
8. Ikeda Y, Takami H, Niimi M, et al. Endoscopic thyroidectomy by the axillary approach. Surg Endosc.
2001;15(11):1362– 1364.
9. Ikeda Y, Takami H, Niimi M, et al. Endoscopic thyroidectomy and parathyroidectomy by the axillary
approach. A preliminary report. Surg Endosc.
2002;16(1):92–95.
10. Ikeda Y, Takami H, Niimi M, et al. Endoscopic total
parathyroidectomy by the anterior chest approach
for renal hyperparathyroidism. Surg Endosc.
2002;16(2):320–322.
11. Chantawibul S, Lokechareonlarp S, Pokawatana C.
Total video endoscopic thyroidectomy by an axillary approach. J Laparoendosc Adv Surg Tech A.
2003;13(5):295–299.
12. Inabnet WB, 3rd, Jacob BP, Gagner M. Minimally
invasive endoscopic thyroidectomy by a cervical
approach. Surg Endosc. 2003;17(11):1808 –1811.
13. Duncan, T, Ejeh, A, et al. Thyroidectomy using an
endoscopic transaxillary approach: our early experience. In press. ■
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Jiang Fan Zhu, MD
AsianAmerican Multispecialty Summit III
A UNIQUE EXCHANGE OF CULTURE
AND EDUCATION...
ORGANIZATIONS
Aaegean Surgical Society – Izmir
Ataturk Training Hospital – Izmir
Celal Bayar University – Manisa
Indian Association of Gastrointestinal Endosurgeons
(IAGES)
Indian Association of Gynecological Endoscopists
Japan Society of Gynecologic Obstetric Endoscopy
(JSGOE)
Japanese Society for Endoscopic Surgery
Korean Society of Gynecologic Endoscopy Group
(KGEG)
Korean Society of Laparoscopic & Endoscopic Surgery
Princess Royal University Hospital
Queen Mary Hospital
Sri Ramachandra Medical College & Research Institute
Surgical Society of Trichy – India
Thai Society of Gynecological Endoscopists (TSGE)
The Association of Minimal Access Surgeons of India
(AMASI)
The Association of Surgeons of India (ASI)
University of Hawaii – Surgical Residency Program
Yonsei University – College of Medicine
REASONS TO ATTEND
• Experience a unique summit offering a multispecialty approach to minimally invasive surgery
• Expand your knowledge of the use of laparoscopic diagnostic and treatment techniques
taught by acknowledged leaders in their respective specialties and countries.
• Topics are presented in general sessions providing a multidisciplinary approach to specialty
minimally invasive surgical techniques and procedures.
• Understand how different countries have met
the challenges of training and practicing minimally invasive surgery.
• Learn about the cultural differences and similarities between neighboring countries.
ATTENDEE OBJECTIVES
The objectives of this program are to provide attendees with:
• A multidisciplinary and multicultural exchange of information between surgeons representing their country or a professional organization on the challenges faced practicing and teaching minimally invasive surgeons.
• A clearer concept of new and standard laparoscopic and endoscopic instrumentation and techniques and how they enhance the standards of patient
care and education of minimally invasive surgeons.
CONFERENCE HOTEL / ACCOMMODATIONS
The Hilton Hawaiian Village Beach Resort and Spa
2005 Kalia Road • Honolulu, Hawaii 96815, USA
Tel: (808) 949-4321 • Fax: (808) 947-7898
Website: www.hiltonhawaiianvillage.com
Located on Wakiki’s widest stretch of beach, the Hilton Hawaiian Village Beach
Resort and Spa features lush tropical gardens, waterfalls, and exotic wildlife.
The resort is a perfect blend of luxurious accommodations, spa facilities, over
20 restaurants and lounges, shopping, recreational and cultural activities,
nightly entertainment, and more.
Tropical-themed, air-conditioned rooms are extra spacious for comfort and
offer balconies with views, cable television, high-speed internet access,
modem/data port hook-ups, voice mail, video game console, hair dryer,
coffee/tea maker, in-room safe, iron/ironing board, clock radio, and refrigerator.
All rooms offer one king or two double beds. Non-smoking rooms are available.
Hit the beach for surfing, boogie boarding, and swimming (surfboards, boogie
boards, kayaks, ocean rafts, snorkel sets, and umbrella-and-beach-chair sets
can be rented on the beach). Outrigger canoes and catamarans offer rides from
the beach. Catch an underwater discovery tour on the Atlantis Submarine from
the Village’s pier. Skydiving, parasailing, helicopter/airplane sightseeing, and
nature/wildlife tours are available in the area surrounding the hotel. Enjoy a
game of golf or tennis, horseback riding, jet skiing, waterskiing, sailing, fishing,
boating, snorkeling, scuba diving, and kayaking – all either on or nearby the
resort’s property. Please make your reservations early!
CALL NOW AND MAKE YOUR RESERVATIONS
Accreditation The Society of Laparoendoscopic Surgeons (SLS) is accredited
by the Accreditation Council for Continuing Medical Education to provide continuing medical education to physicians.
Designation The SLS designates this educational activity for a maximum of
16.5 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
CONFERENCE FEES
SLS Members, Delegates & Organizing Committee: Register Online at www.SLS.org
before December 6, 2007 and save an additional $100 on your conference registration!
Members
$595
Non-Members
$595
Delegates/Organizing Committee Members
$495
Resident/Nurse/Fellow
Scholarships are available for qualified Residents-inTraining, Fellows-in-Training, Nurses, and affiliated
Medical Personnel. Visit www.SLS.org for details.
AsianAmerican Multispecialty Summit III
PRELIMINARY PROGRAM AGENDA
WEDNESDAY, FEBRUARY 6, 2008
3:00 – 6:00pm
CONFERENCE REGISTRATION
6:00 – 7:00pm
OPENING CEREMONY AND WELCOME Paul Alan Wetter, MD, Chairman. Delegation Introductions: Organizing Committee Chairs
Cultural Presentations. Entertainment
7:00 – 8:00pm
WELCOME RECEPTION
THURSDAY, FEBRUARY 7, 2008
7:00 – 7:30am
7:30 – 7:45am
CONTINENTAL BREAKFAST
OPENING REMARKS Paul Alan Wetter, MD, Chairman
MULTIDISCIPLINARY: Moderators: William E. Kelley, Jr., MD & Elspeth. M. McDougall, MD
7:45 – 8:00am
Understanding Endoscopic Anatomy of Inguinal Region, Parveen Bhatia, MD • India
8:00 – 8:15am
Minimally Invasive Surgery in the Developing World – Obstacles Encounter, Success Achieved, Racquel Bueno, MD • USA
8:15 – 8:30am
Education and Training for Endoscopic Surgery – Basic Fundamentals and Advanced Techniques, Kazuo Tanoue, MD • Japan
8:30 – 8:45am
Cultural Presentation
8:45 – 9:00am
Spleen and Its Vessels Preserving Laparoscopic Distal Pancreatectomy (Reviewing 30 Cases), Ho-Seong Han, MD • Korea
GENERAL SURGERY: Moderators: Michael S. Kavic, MD & Raymond J. Lanzafame, MD, MBA
9:00 – 9:15am
Hand-Assisted Laparoscopic Splenectomy and Devascularization for Portal Hypertension, Jiang Fan Zhu, MD • China
9:15 – 9:30am
Cultural Presentation
9:30 – 9:45am
BREAK
9:45 – 10:00am
Laparoscopy Hysterectomy and Its Complications, Shelia Mehra, MD • India
10:00 – 10:15am
Laparoscopic Hysterectomy is Still a Provocation for the Classic Gynecologist, Liselotte Mettler, Prof Dr Med • Germany
10:15 – 10:30am
Cultural Presentation
10:30 – 10:45am
Endoluminal Management of Pseudopancreatic Cyst, Parveen Bhatia, MD • India
10:45 – 11:00am
Natural Orifice Translumenal Endoscopic Surgery, Racquel Bueno, MD • USA
11:00 – 11:15am
Cultural Presentation
11:15 – 11:30am
Correlation of Hysteroscopy with 3-D Ultrasoography, Mamatha Deendayal, MD • India
HYSTERECTOMY: Moderators: Maurice K. Chung, MD & Farr Nezhat, MD
NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY: Moderators: Harrith M. Hasson, MD & Michael S. Kavic, MD
GYNECOLOGY: Moderators: Charles H. Koh, MD & Carl J. Levinson, MD
11:30 – 11:45am
Is it Necessary to Perform Pre-IVF Hysteroscopic Evaluation, Aygul Demirol, MD • Turkey
11:45 – 12:00pm
Hysteroscopic Fallopian Tube Recanalisation, Sundar Narayanan, MD • India
12:00 – 12:15pm
Minimally Invasive Esophagectomy for Cancer, Simon Law, MD • China
12:15 – 12:30pm
Leuprorelin Acetate Therapy in Patients with Uterine Myoma Prior to Laparoscopic Hysterectomy and Myomectomy, Misuru Shiota, MD • Japan
6:00 – 8:00pm
SPECIAL SLS Social Event with Faculty: Luau Under the Stars
LAPAROSCOPY IN CANCER: Moderators: Tommaso Falcone, MD & Liselotte Mettler, Prof Dr Med
FRIDAY, FEBRUARY 8, 2008
7:00 – 7:30am
CONTINENTAL BREAKFAST
MULTIDISCIPLINARY: Moderators: Charles H. Koh, MD & Elspeth M. McDougall, MD
7:30 – 7:45am
Laparoscopic Management of Pelvic Emergencies, Vishwanath Pai, MD • India
7:45 – 8:00am
No Future without Suture – Art of Endosuturing, Parveen Bhatia, MD • India
8:00 – 8:15am
Cultural Presentation
GENERAL SURGERY: Moderators: Maurice K. Chung, MD & Raymond J. Lanzafame, MD, MBA
8:15 – 8:30am
Laparoscopic Hemicolectomy for Ileocaecal Tubersulosis, Vishwanath Pai, MD • India
8:30 – 8:45am
Scarless Endoscopic Surgery: from NOTES to Tues, Jiang Fan Zhu, MD • China
8:45 – 9:00am
Justice to Gallstone Sufferers: Our Experience With Over 1000 Patients, Tushar Samdani, MD • England
9:00 – 9:15am
Cultural Presentation
laparoscopy today 29
(program continued on page 30)
AsianAmerican Multispecialty Summit III
PRELIMINARY PROGRAM AGENDA (continued from page 29)
COLORECTAL & HERNIA: Moderators: Michael S. Kavic, MD & Farr Nezhat, MD
9:15 – 9:30am
Laparoscopic Repair of Margagni Hernias in Adults, Atilla Cokmez, MD • Turkey
9:30 – 9:45am
Colorectal & Hernia, Zameer Pasha, MD • India
9:45 – 10:00am
Laparoscopic Repair of Ventral Hernias, What We Have Learned From Our Initial Experience, Aslan Sakarya, MD • Turkey
10:00 – 10:15am
Laparoscopic Colorectal Resection for Malignancy: An evaluation of Oncologic Outcome, Wai Lun Law, MD • China
10:15 – 10:30am
BREAK
10:30 – 10:45am
Robotic/Laparoscopic Surgery in Korea—Prostate, KH Rha, MD • Korea
ROBOTICS: Moderators: William E. Kelley, Jr., MD & Elspeth M. McDougall, MD
10:45 – 11:00am
Safety of Laparoscopic Cholecystectomy: 1. Biliary Imaging, 2. Robotic Surgery (Preliminary Experiment), Kunihiko Izuishi, MD • Japan
11:00 – 11:15am
DaVinci-Assisted Low Anterior Resection for Rectal Cancer, Seung Hyuk Baik, MD • Korea
MULTIDISCIPLINARY: Moderators: Maurice K. Chung, MD & Richard M. Satava, MD
11:15 – 11:30am
Newer Horizons in Laparoscopic Surgery, Parveen Bhatia, MD • India
11:30 – 11:45am
Pitfalls in Preoperative Evaluation & General Anesthesia in Laparoscopy Patients, Alp Yentur, MD • Turkey
11:45 – 12:00pm
Cultural Presentation
HYSTERECTOMY: Moderators: Harrith M. Hasson, MD; Carl J. Levinson, MD & Liselotte Mettler, Prof Dr Med
12:00 – 12:15pm
Strategies to Make Total Laparoscopic Hysterectomy Simple Safe as well as Effective, Prashant Mangeshikar, MD • India
12:15 – 12:30pm
Need for Re-Classification or the Modification of Laparoscopic Hysterectomy, Paul I. Lee, MD • Korea
SATURDAY, FEBRUARY 9, 2008
7:00 – 7:30am
CONTINENTAL BREAKFAST
BARIATRICS: Moderators: Raymond J. Lanzafame, MD, MBA & Gustavo Stringel, MD
7:30 – 7:45am
Bariatric Surgery in the Developing World, Racquel Bueno, MD • USA
7:45 – 8:00am
Obesity in the Asian Population, Racquel Bueno, MD • USA
8:00 – 8:15am
Cultural Presentation
HEPATOBILIARY: Moderators: • William E. Kelley, Jr., MD & Charles H. Koh, MD
8:15 – 8:30am
Laparoscopic Cholecystectomy in Tuberculosis of Abdomen, When to Operate? Venugopa Venkatesh, MD • India
8:30 – 8:45am
Laparoscopic Cholecystectomies in Patients Over 65 Years of Age, Aslan Sakarya, MD • Turkey
8:45 – 9:00am
Laparoscopic Liver Resections for the Lesions in the Different Locations, Ho-Seong Han, MD • Korea
9:00 – 9:15am
Cultural Presentation
9:15 – 9:30am
Endoscopic Breast Surgery—Scarless Excision, Brij Bhushan Agarwal, MD • India
HERNIA: Moderators: Tommaso Falcone, MD & Harrith M. Hasson, MD
9:30 – 9:45am
Who Should Be Doing Surgery in Pelvic Endometriosis? Is There a Need to Certify Such Surgeon? Paul I. Lee, MD • Korea
9:45 – 10:00am
Laparoscopy in Emergency Surgery, Venugopa Venkatesh, MD • India
10:00 – 10:15am
Management of the Surgical Center for Smooth Endoscopic Surgery and Efficient Use of Operative Rooms, Hisashi Usuki, MD • Japan
10:15 – 10:30am
Break
HEPATOBILIARY: Moderators: Richard M. Satava, MD & Gustavo Stringel, MD
10:30 – 10:45am
Laparoscopic Cholecystectomy Without Using Any Energy Source—Ensuring Better Results, Brij Bhushan Agarwal, MD • India
10:45 – 11:00am
Approach and Management of Bile Leaks After Laparoscopic Cholecystectomies , Atilla Cokmez, MD • Turkey
11:00 – 11:15am
Cultural Presentation
GYNECOLOGY: Moderators: Tommaso Falcone, MD & Farr Nezhat, MD
11:15 – 11:30am
Laparoscopic Salpingectomy for the Patients With Hydrosalpinx Before IVF, Erdal Aktan, MD • Turkey
11:30 – 11:45am
Ten Years Review of Chronic Pelvic Pain Via Laparoscopy in Siriraj Hospital, Thailand, Pongsakdi Chaisilwattana, MD • Thailand
11:45 – 12:00pm
Laparoscopic Endometrioma Cystectomy Before IVF, Aygul Demirol, MD • Turkey
12:00 – 12:15pm
Cultural Presentation
12:15 – 12:30pm
DELEGATES MEETING
30 laparoscopy today
Laparoscopy Web
WEBSURG.com has partnered with
McMaster University to offer the opportunity to obtain up to 41 CME credits
through videos, techniques, and lectures.
ISMICS.org, website of
the International Society
for Minimally Inasive
Cardiothoracic
Surgery, n o w
offers highlights
from the 2007
A n n u a l
Scientific
Meeting.
Archives and
highlights featuring abstracts
and video and
audio presentations
are available starting
with the 2001 conference.
UROLOGYTIMES.com /
CONTEMPRARYUROLOGY.com
Always offering the latest in urology
news, recent issues featured “Robotic
Radical Prostatectomy Shows Good
Oncologic, Functional Outcomes;”
“Robotic Prostatectomy: Is It Fulfilling
Expectations?;” and “Endoscopy May be
Effective in Select TCC Patients.”
laparoscopy today 31
MEDPAGETODAY.com Use the sites
RSS feeds to stay abreast of news
across numerous specialties and to
earn CME credits Recently posted
teaching briefs include “When a
Robot Does Rounds Patients Get
Faster Discharge,” “Bariatric Surgery
Appears Safe for Selected Older
Patients.” And, if you couldn’t make it
to a conference in person or just
couldn’t get to all the lectures on your
hot topic of choice, take a look at the
conference reports. From the ACS
meeting to the World Transplant
Congress, this site has it covered.
ASLMS.org, home of the American Society
for Laser Medcine and Surgery, contains
standards of practice, provides patient
information and now allows site visitors to
view annual meeting eposters through the
ImageStore for healthcare.
SLS.org / LAPAROSCOPYTODAY.com
are your gateways to free access. Visit
these sites to download the full text of
all the articles published in JSLS, Journal
of the Society of Laparoendoscopic
Surgeons and Laparoscopy Today. SLS
Annual Meeting and Multispecialty
Summit information as well as the complete text of the first edition of
Prevention and Management of
Laparoendoscopic Surgical Complications
are also available.
JOURNAL WATCH: PROTO
The Body in Pain. Gorman RM. Spring
2007:23-27 • Gorman points out that
10% of Americans suffers chronic pain
lasting at least a year and that pain is
the reason for 20% of doctor visits; but
why is an ache to one person, complete
agony to another, why does one type of
anagelsic work well for person A and
offer no relief to person B? In an effort
to come close to answering these questions, the author explores the role of
genetics, explains the nature and types
of pain, and gives readers an overview
of how different types of drugs target
pain.
JOURNAL WATCH: Minim Invasive Therapy
M i n i m a l l y I n v a s i v e T h e r a p y.
Buess GF and Kanehira Eiji
eds. 2007;16(2):75-126 • The issue
focused on Microsystems in Medicine
and included an overview of
microtechnologies. Other articles
included Microrobotics for Future
Gastrointestinal Endoscopy, an article
on MEMS for enhanced optical diagnostics, and MST development for
medical application.
JOURNAL WATCH: Surg Endosc
Transvesical Thoracoscopy: A
Natural Orifice Translumenal
Endoscopic
A p p ro a c h
for
Thoracic Surgery. Lima E et al.
Spring 2007;21(2):854-858 • .After
performing endoscopic t r a n s vesical diaphragmatic thor a c o s c o p y with lung biopsy on
six pigs, the authors concluded
that the procedure is techically
feasible in the porcine model.
They note that more work and
new instruments are needed before
the procedure could be translated
to humans.
CME Opportunities | Calendar of Events
Events Presented by the Society of Laparoendoscopic Surgeons
September 5-8, 2007 16th SLS Annual
Meeting and Endo Expo 2007.
Hyatt Regency San Francisco.
San Francisco, California, USA
September 17-20, 2008 17th SLS Annual
Meeting and Endo Expo 2008.
Hyatt Regency McCormick Place.
Chicago, Illinois, USA
February 6-9, 2008 AsianAmerican
MultiSpecialty Summit III Laparoscopy and
Minimally Invasive Surgery.
Hilton Hawaiian Village Beach
Resort and Spa. Honolulu, Hawaii, USA
February 11-14, 2009 EuroAmerican
MultiSpecialty Summit IV Laparoscopy and
Minimally Invasive Surgery.
Disney’s Contemporary Resort.
Orlando, Florida, USA
OCTOBER 2007
4-7 Innovations & EBM in Urology.
Hellenic Urological Association.
Athens, Greece
7-11 ACS 93rd Clinical Congress. American
College of Surgeons. New Orleans,
Louisiana, USA
12-17 The ACG Annual Scientific Meeting and
Postgraduate Course. American College
of Gastroenterology. Philadelphia,
Pennsylvania, USA
20-22 APAGE Regional Meeting. AsiaPacific Association of Gynecologic
Endoscopy & Minimally Invasive
Therapy. Xian, China
20-Nov 3 25th World Congress of
Endourology and SWL. Endourological
Society. Cancun, Mexico
24-27 70th Annual Colon and Rectal Surgery
Conference. University of Minnesota
Division of Colon and Rectal Surgery.
Minneapolis, Minnesota, USA
25-27 IPPS Annual Scientific Meeting.
International Pelvic Pain Society. San
Diego, California, USA
NOVEMBER 2007
8-11 The 2nd Asia Pacific Congress on
Controversies in Obstetrics, Gynecology &
Infertility. Comtechmed Medical
Conferences. Shanghai, China
15-17 Global Congress of Minimally Invasive
Gynecology. AAGL 36th Annual Meeting.
AAGL. Washington, DC, USA
17-18 Hand-assisted Laparoscopy–AUA
Surgical Learning Center Course. American
Urological Association. Houston,
Texas, USA
laparoscopy today 32
28-Dec 2 ISMICS Winter Workshop. The
International Society of Minimally
Invasive Cardiothoracic Surgery.
Antalya, Turkey
DECEMBER 2007
8-10 9th International Workshop on
Therapeutic Endoscopy. European Society
of Gastrointestinal Endoscopy/
American Society for Gastrointestinal
Endoscopy. Cairo, Egypt
JANUARY 2008
24-26 MIRA 2008. 3rd International
Congress. Minimally Invasive Robotic
Association. Rome, Italy
FEBRUARY 2008
6-9 AsianAmerican MultiSpecialty Summit
III Laparoscopy and Minimally Invasive
Surgery. Society of Laparoendoscopic
Surgeons. Honolulu, Hawaii, USA
17-20 7th Annual Surgery of the Foregut
Symposium & Endoscopy/Natural Orifice
Surgery Workshop. Cleveland Clinic
Florida. Coral Gables, Florida, USA
MARCH 2008
11-14 10th World Congress on
Endometriosis. World Endometriosis
Society. Melbourne, Australia
APRIL 2008
9-12 SAGES Scientific Session &
Postgraduate Course. Society of American
Gastrointestinal Endoscopic Surgeons.
Philadelphia, Pennsylvania, USA
MAY 2008
3-7 ACOG Annual Clinical Meeting.
American College of Obstetricians and
Gynecologists. New Orleans,
Louisiana, USA
For more information about these and other
upcoming events, visit www.Laparoscopy.org
17-22 AUA Annual Meeting. American
Urological Association. Orlando,
Florida, USA
JUNE 2008
4-7 World Congress of Gynecologic
Endoscopy. International Society of
Gynecologic Endoscopy. Bari, Italy
7-12 ASCRS Annual & Scientific Meeting.
American Society of Colon & Rectal
Surgeons (ASCRS). Boston, Massachusetts,
USA
SEPTEMBER 2008
2-6 ELSA 2008 in conjunction with 11th
World Congress of Endoscopic Surgery and
21st Annual Meeting of Japan Society for
Endoscopic Surgery. Endoscopic and
Laparoscopic Surgeons of Asia.
Yokohama, Japan
17-20 17th SLS Annual Meeting and Endo
Expo 2008. Society of Laparoendoscopic
Surgeons. Chicago, Illinois, USA
OCTOBER 2008
12-16 ACS 94th Clinical Congress. American
College of Surgeons. San Francisco,
California, USA
29-Nov 1 Global Congress of Minimally
Invasive Gynecology/AAGL 37th
Annual Meeting. American Association
of Gynecologic Laparoscopists. Las
Vegas, Nevada, USA
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Harmonic ACE™ offers the multifunctionality and
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*When compared with LCSC5.
©2005 Ethicon Endo-Surgery, Inc.
All rights reserved. DSL#05-1084