Abstracts of Presentations Made at MISWeek 2025, September 10–13, 2025 Lake Buena Vista, Florida, USA

Objective: Crohn’s disease affects the colorectum in 30% of cases. In this population, the risk of developing colorectal cancer increases over time, reaching approximately 3% at 10 years after diagnosis and 7% at 30 years, with an average age of onset ranging between 40 and 50 years. Here, we present the unusual case of a 29-year-old female who underwent a robotic proctocolectomy just 5 years after diagnosis, with stage III adenocarcinoma incidentally diagnosed on final pathology. Methods and Procedures: Preoperative surveillance colonoscopy revealed medically refractory Crohn’s proctocolitis with several biopsies showing high-grade dysplasia. A robotic proctocolectomy with combined abdominal and perineal resection was performed. Intraoperative fluorescence imaging (IFI) with indocyanine green (ICG) was utilized to facilitate visualization of the ureters in an inflamed pelvis. The specimen was sent to pathology. Results: Proctocolectomy was successfully completed robotically. IFI with ICG facilitated ureteral visualization throughout the procedure. Final pathology revealed chronic severe colitis, multifocal intramucosal carcinoma, and adenocarcinoma in 1 of 75 lymph nodes. Proximal and distal resection margins were negative. The patient recovered uneventfully. Conclusion: Surgical management for medically refractory Crohn’s proctocolitis consists of proctocolectomy with end ileostomy. Resection is also indicated when high-grade dysplasia is present, given a 40% incidence of associated carcinoma. Our case demonstrates the rare development of a stage III adenocarcinoma in a young patient only 5 years after diagnosis. It also illustrates the utility of fluorescence imaging technology for improved visualization and preservation of the ureters during complex pelvic surgery.

Objective: Prostatic urethral lift (PUL) is widely adopted as a minimally invasive surgical option for benign prostatic hyperplasia. This study reviewed all device complaints for the last 10 years. Methods: We queried 342 reports from the Manufacture and User Facility Device Experience database (MAUDE) between 01/01/2015 to 12/31/2024. Reports were classified accordingly. We used Mann- Kendall trends and Linear Regression to assess and compare trend strengths with PUL cases numbers from the Medicare National Summary Data File (NSDF) between 2015 to 2023, using p < 0.05. Results: There are significant increasing trends in both the number of NSDF cases and MAUDE complaints with strong coefficient of determination (R 2 =0.9 and 0.88 respectively). According to NSDF, the number of PUL procedure has increased from 1420 in 2015 to 18908 in 2023. The most common device issues were “Needle Fragmentation” (21.6%) and “Failure to Fire/Misfire” (7.6%). Most cases (71%) were Gupta level 1 or 2 (requiring no or minor intervention), while 29% cases were Gupta level 3 or 4, (requiring major intervention or resulting in life-threatening event/death). The most common adverse events (AEs) were hematoma (14.5%) and hemorrhage (8.8%), and 70% of complaints required for major intervention. There were 12 cases of death (3.5%) with 4 cases that were possibly related to PUL complications including hematoma and sepsis. In addition, no significant trends were observed in the proportion of reported serious AEs or hematoma cases. Conclusion: As the number of PUL procedure is increasing, surgeons should be aware of common device problems and severe AEs in PUL.

Objective: Obesity rates are increasing, and in the United States, adults aged 45–54 have the highest obesity rate. Gastric bypass surgery (GBS) is a procedure for individuals with severe obesity. This study examines demographic differences among patients undergoing GBS in New York from 2019–2022 to identify groups with differing likelihoods of undergoing the procedure. Methods and Procedures: This retrospective analysis utilized the Statewide Planning and Research Cooperative System Inpatient De-Identified dataset, containing New York State inpatient discharge data. Patient age and insurance type were examined. χ 2 tests assessed differences, with odds ratios (OR) and 95% confidence intervals (CI) calculated using private insurance and the 30–49 age group as reference categories. Results: A total of 10,172 procedures meeting inclusion criteria were analyzed. All age groups were less likely to undergo GBS than the reference category. Patients 30–49 were about 7 times more likely to have GBS than those 18–29 (2019 OR: 7.01 [6.06–8.11], 2022 OR: 7.13 [6.29–8.08]) and 2–3 times more likely than those 50–69 (2019 OR: 2.03 [1.80–2.28], 2022 OR: 2.83 [2.54–3.15]). For insurance, there was no significant difference between private and public insurance patients. Conclusion: Findings suggest worsening disparities in GBS utilization across age groups, with individuals outside 30–49 significantly less likely to undergo the procedure. Given obesity rates are highest among individuals aged 45–54, ensuring access to GBS for those 50+ is critical. Further research is needed to explore causes and ensure equitable access.

Background: Aggressive surgical resection strategy for colorectal liver metastasis has been shown to be safe and effective. Hepatic venous deprivation (HVD) is an emerging technique to induce future liver remnant hypertrophy in patients requiring extended hepatectomy at risk for developing posthepatectomy liver failure. This method is considered a nonsurgical alternative to ALPPS procedure and it had been shown to be more effective than portal vein embolization alone. Herein, we describe application of HVD in patient with multifocal bilateral colorectal liver metastasis. Method: A 66-year-old woman with bilobar colorectal liver metastasis from sigmoid colon presented to our office. She underwent 6 months of neoadjuvant Folfox chemotherapy. First stage of the operation included robotic nonanatomical liver resections to remove metastatic tumors in the future liver remnant (segment 1, 2/3, and 4) in conjunction with resection of the primary sigmoid cancer. Due to borderline FLR volume (29–30%) HVD was performed by embolizing the right portal vein and hepatic vein simultaneously. Four weeks after the HVD, FLR volume has increased to 40%, which enabled safe open extended right hepatectomy to be performed at 2nd stage. Results: Both stages of the operation were completed uneventfully without postoperative complications. Resection of right diaphragm with primary repair was necessary at the 2nd stage due to direct tumor invasion. The patient is currently 1 year with no evidence of disease. Conclusion: A two-stage liver resection with hepatic venous deprivation is safe and effective in management of bilobar metastatic colorectal liver cancer in patients who are otherwise considered unresectable.

★ Honorable Mention: Michael S. Kavic Award for Best Scientific Paper by a Resident Objective: Minimally invasive surgical procedures often require organ retraction for optimal visualization. Upper GI (UGI) surgeries require liver retraction to visualize the stomach and diaphragmatic hiatus. However, many existing liver retractors are rigid and can cause injury or transaminitis due to compression of liver parenchyma. To address these limitations, a percutaneously-placed, atraumatic, suction-based retractor was designed to achieve organ retraction with similar visualization. The present study is aimed to evaluate this devices’ effectiveness in retraction during UGI surgeries. Methods: This single-center, two-surgeon, prospective study was conducted between Jul and Dec 2023. Data was collected via physician survey. Surgeries included: sleeve gastrectomy, hiatal hernia repair, Roux-en-Y gastric bypass, cholecystectomy, and gastric lap band removal. Exclusion criteria included history of cirrhosis, coagulopathy, hemangioma, or other liver pathology. This device consists of a silicone cup and tubing, with a mesh sponge insert. The cup was placed on the liver undersurface laparoscopically and connected to external suction (190-200mmHg), forming a seal for atraumatic liver retraction. Results: This device was deployed in nine surgeries, with average patient age of 46 years. 89% of patients were female. Based on physician survey, intra-abdominal adhesions were present in four cases and average length of retraction was 138 minutes. Adequate retraction was achieved in 89% of cases. Stated benefits included fewer ports and less lysis of adhesions. No injuries were noted from this device. Conclusion: This device demonstrated effective retraction in UGI procedures, addressing limitations of traditional rigid retractors and offering the benefit of fewer ports with no liver injury recorded.

★ Michael S. Kavic Award for the Best Scientific Paper by a Resident Background: We previously reported a three port technique for laparoscopic and robotic assisted cholecystectomy (LC&RAC). Indocyanine green (ICG) cholangiography makes LC&RAC safer but universal use is limited by institutional barriers and surgeons attitudes. Patients and Methods: In 108 of 349 consecutive LC&RACs (2013–2025) performed at four different hospitals ICG cholangiography was used (31%), in 93 cases (27%) a three instrument technique was possible. There were two rural hospitals (centers 1, 2), one suburban facility (Center 3) and one inner city community hospitals (Center 4), two had academic affiliation. Briefly, after creation of a window behind the gallbladder, ICG enhanced critical view of safety was obtained and cystic artery and duct were secured. Pinpoint system (n = 23), old Spy (n = 6), new Spy system (n = 72) and Firefly robotic X and ξ platforms (n = 7) were used. Results: Center 1 had no robotic system, ICG platforms were available during trials, in Center 2&3 ICG was available for LC, RAC was heavily restricted. In center 4 no laparoscopic ICG system was provided but RAC was accessible. Best visualization (ICG over white light) was provided with Pinpoint (but requires a 12 mm port). The old Spy system performed poorest, the new Spy system was most commonly used; the robotic Firefly system is restricted to either white light or ICG mode. Conclusions: ICG enhancement further improves safety of our three instruments LC&RAC technique. Acceptance and availability of ICG cholangiography is changing - it is a great tool to make LC&RAC easier and should be promoted especially in resident training.

★ The Medical Educator Consortium Award for Best Scientific Paper Objective: Evaluate efficacy of sclerotherapy in improving reproductive outcomes of women with ovarian-endometrioma undergoing In-vitro-fertilization (IVF). Methods and Procedure: Prospective, nonrandomized, parallel-arm pilot study, carried out following ethics approval (CTRI/2024/01/061442).Infertile women aged 21–40 years with endometriomas 2-6cm,undergoing IVF were recruited.30-per-group (sclerotherapy and expectant) was taken. Sclerotherapy group underwent transvaginal ethanol instillation under ultrasound-guidance during immediate postmenstrual period. Endometriotic cyst aspirated aseptically,8–30 ml of 95% ethanol (60% of cyst volume) was instilled using 17G oocyte aspiration needle under ultrasound-guidance, leaving ethanol for 10 minutes. Ovarian reserve was assessed by measuring serum Anti-Mullerian Hormone(AMH) levels and antral follicle count (AFC) for three consecutive months. Women with optimal ovarian reserve(AMH > 1ng/ml AFC > 5) were considered for IVF, while expectant group proceeded directly to IVF. Primary outcomes were changes in endometrioma size & ovarian reserve, while secondary outcomes focused on reproductive metrics, number of oocytes retrieved, number of embryos, implantation rate, clinical pregnancy rate, live birth rate between two groups. Statistical analysis was performed using STATA version 17.0-software. Results: Sclerotherapy led to reduction in endometrioma size from 3.65 ± 0.70 cm-1.2 ± 0.8 cm (p = 0.01). AMH levels increased from 2.75 ng/ml-3.45 ng/ml (p < 0.001) and AFC improved from 7.1 to 10 (p < 0.001). IVF outcomes showed significant improvements between sclerotherapy and expectant groups, with sclerotherapy group having higher number of oocytes retrieved (6.5 vs 3.9, p = 0.001), more embryos (3.6 vs 2.2, p = 0.003), higher implantation rates (40.9% vs 13.3%, p = 0.03) & higher clinical pregnancy rates (40.9% vs 13.3%,p = 0.03). Ongoing pregnancy rates and live birth rates were also higher in sclerotherapy group (36.36% vs 13.33%, p = 0.05). Conclusion: Sclerotherapy is minimally invasive, outpatient procedure offering effective alternative to cystectomy for managing endometriomas before IVF, without negatively impacting ovarian reserve.

Objectives: Salmonella Typhi and Paratyphi A have been reported as rare causes of acute acalculous cholecystitis (AAC). Here, we present a single case of AAC caused by Salmonella Paratyphi A in an otherwise healthy 26-year-old female patient at our institution. Methods: This is an observational case report with retrospective chart review of one patient diagnosed with AAC who was treated at our academic tertiary care center. Results: Our patient was diagnosed with Grade I acute cholecystitis according to the 2018 Tokyo guidelines and underwent robot-assisted laparoscopic cholecystectomy revealing empyema of the gallbladder. Pathology revealing AAC with pus growing Salmonella Paratyphi A. Conclusion: Salmonella should remain on the differential as a potential pathogen in patients presenting with AAC. Cultures at the time of operation should be considered in those with no clear risk factors for the development of AAC.

Objective: Alcoholic pancreatitis is one of the most common forms of pancreatitis and has many complications, a rarer complication being the splenic pseudocyst. Here, we report a case of alcoholic pancreatitis causing a splenic pseudocyst and its management. Methods and Procedures: The patient is a 41 year old man with past medical history of hypertension, hyperlipidemia, hypertriglyceridemia and chronic pancreatitis, presenting with abdominal tenderness in both right(RUQ) and left(LUQ) upper quadrants, nausea, vomiting, diarrhea, hypotension and weight loss. This was preceded by ingestion of alcohol. On physical examination, his abdomen was soft, severe pain elicited in RUQ and LUQ, but otherwise normal. Computed tomography of abdomen and pelvis images were taken to evaluate original pseudocyst collection, size changes and treatment effectiveness. Interventional radiology and gastroenterology each attempted drain placement; two percutaneous drainages, one resulting in a pigtail drain and an endoscopic retrograde cholangiopancreatography (ERCP) drainage w/placement of a lumen apposing metal stent (LAMS) respectively. General surgery conducted outpatient management. Results: The original collection size was 15 × 5.5 × 17 centimeters. The initial IR procedure removed 490 milliliters of fluid. With fluid reaccumulation, the pseudocyst measured at 12.6 × 6.0 × 16.4 centimeters. The second procedure drained 580 milliliters of fluid. The case was escalated to LAMS placement by GI, due to worsening of pancreatic and splenic pseudocysts. Conclusion: Conservative management of splenic pseudocysts is preferred depending on size, location and impact to the organ’s functionality. Oversized pseudocysts lean towards total splenectomy, but as shown here, can also be managed effectively with conservative measures.

★ Gustavo Stringel Award for Best Poster by a Student Objective: Individual serum electrolyte levels have been shown to predict hospitalization outcomes. A combined Ion Index incorporating four individual electrolyte values has been reported to predict poor outcomes after cardiac arrest. We hypothesized that this integrated Ion Index would more strongly predict mortality than single electrolyte values in patients who underwent robotic-assisted pulmonary lobectomy (RAPL). Methods and Procedures: We retrospectively analyzed 832 consecutive patients who underwent RAPL between Sep 2010 through Jan 2025. Potassium, magnesium, calcium, and phosphate levels were collected at five perioperative timepoints: Preoperative, Post-Anesthesia Care Unit, Post-Operative Day #1, Lowest, Highest, and Discharge. These electrolyte values were used to calculate Ion Index scores at each timepoint using the formula: “(Potassium+Magnesium+Phosphate)/Calcium”. Preoperative phosphate and ionized calcium levels were unavailable for most patients and were excluded from Ion Index calculations. Univariate logistic regression was performed to evaluate associations. Results: Among 794 evaluable patients, the novel Ion Index was a stronger predictor of in-hospital and 30-day mortality than single electrolyte values. Among the five perioperative time points, the Discharge Ion Index was the best predictor of perioperative mortality, with an odds ratio (OR) of 1.26 (p < 0.001) for in-hospital mortality and an OR of 1.14 (p < 0.001) for 30-day mortality. These values surpassed the predictive strength of any individual electrolyte. Conclusion: The novel Ion Index, which is a simple measure of electrolyte imbalance, predicts postoperative in-hospital and 30-day mortality following RAPL better than individual electrolyte values and may help clinicians more quickly assess a patient’s risk of perioperative mortality.

Objective: Most laparoscopic/robotic assisted cholecystectomies (LC, RAC) are done with four ports. We propose a three-port technique using a modified dome down technique. Methods and Procedures: 337 consecutive LCs & 12 RACs performed between 2013 and 2025 at four different hospitals were analyzed. For LC, 5 mm trocars were placed in the LUQ, umbilicus, and between the two. The third trocar was replaced by a needle grasper in 131 cases. For RAC, 8 mm ports were inserted in the LUQ, umbilicus and RLQ. The gallbladder (GB) serosa was incised on both sides, a window was created behind the GB midportion and widened towards fundus and infundibulum. Cystic artery (CA) and duct (CD) were dissected out obtaining the critical view. The last fundus adhesion was cut and CA/CD were secured. Results: Median age of 234 women and 116 men was 51.5 (range 16–90) years. Indications included acute (n = 45), acute/chronic (n = 76), chronic cholecystitis (n = 154), miscellaneous (n = 74). In 298 cases (85%), the procedure was completed with three instruments. Reasons for additional port placement were combined procedures (Foregut 3, bariatric 3, small bowel resection 2, colectomy 3) or poor exposure and difficult cases. There was one conversion in this series and two patients had subtotal cholecystectomy. No complications directly attributable to the 3-instrument technique were observed. Trainees reported a steep learning curve. Conclusions: Three instruments LC and RAC with alternative port placement are feasible and safe and may have ergonomic advantages. Technical adaptations allowed for a high success rate of 85%.

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy preserves the favorable outcomes of vaginal hysterectomy while harnessing laparoscopic visualization. We aimed to compare perioperative outcomes and examine the influence of obesity in hysterectomies via total laparoscopic hysterectomy (TLH) or vNOTES for nonendometriosis benign hysterectomy indications. A retrospective cohort study of patients undergoing benign, nonendometriosis hysterectomies from May 2022 to Mar 2025 by 4 minimally invasive gynecologic surgeons at 2 hospital sites was conducted. Bivariate analysis compared surgical route and body mass index (BMI) to operating room (OR) time, estimated blood loss (EBL), postanesthesia care unit (PACU) time, and hospital days. The study included 99 patients (35 vNOTES, 64 TLH). Overall, vNOTES had a higher median EBL compared to TLH (100 versus 50 mL, p = 0.002). When subcategorized by obesity class, vNOTES had a higher median EBL for Class I obesity (200 versus 40 mL, p = 0.001). OR time, PACU time, and hospital days did not differ significantly by surgical route or obesity class. Uterine weight showed a weak positive correlation with EBL (r s =0.28, p = 0.005) but not with OR or PACU time. The vNOTES group had a lower median BMI (33.8 versus 38.6 kg/m 2 , p = 0.014). Both approaches demonstrated comparable outcomes for OR time, PACU time, and hospital days. The vNOTES route was associated with higher EBL. The lower BMI in this group suggests a selection bias and may be associated with surgeon comfortableness compared to performing TLH. Further research is warranted to refine patient selection and optimize outcomes in obese populations.

Objective: Among the many options considered to combat the rising obesity epidemic, surgical treatment is increasing in utilization. A sleeve gastrectomy (SG) is a surgical procedure to remove part of the stomach to aid in weight loss, and it is necessary to examine the accessibility and impact of surgical alternatives. This study analyzes the likelihood of undergoing SG among patients of varying health insurance status selected from New York State in-patient data from 2019–2022. Methods and Procedures: This retrospective analysis examined data from the Statewide Planning and Research Cooperative System (SPARCS) Deidentified Hospital Inpatient Discharges from 2019–2022. Race/ethnicity, age, gender, and insurance type were the variables surveyed, and Odds Ratios and Confidence Intervals were calculated to evaluate differences and study trends in the data. Results: Health insurance typology included private, public (including Medicare, Medicaid, VA, the Department of Corrections, and other government entities), and self-pay. Of the 26476 gastrectomy procedures, 41% of patients had public health insurance compared to 53% with private insurance. In 2022, the number of patients with public. Conclusion: Traditionally, fewer patients with public insurance would undergo SG compared to those with private insurance. Over the last three years, there is an increase in SG done with public insurance. The rise in SG use may demonstrate increased access to surgical treatments for obesity to a broader population.

PEDIATRIC SURGERY POSTERS ★ Gustavo Stringel Award for Best Poster by a Student Objective: To assess racial and ethnic disparities in prolonged length of stay (LOS) following pediatric appendectomy in New York State between 2018 and 2022. Methods and Procedures: A retrospective analysis was conducted using the 2018–2022 New York State Planning and Research Cooperative System (SPARCS) inpatient database. Pediatric patients (ages 0–17) undergoing appendectomy were identified using Clinical Classifications Software Refined (CCSR) codes. Prolonged LOS was defined as greater than 2 days (≥3 calendar days), consistent with national benchmarks of a 1.5-day average LOS and the SPARCS use of whole-day recording. Race and ethnicity were categorized as Black Non-Hispanic, White Non-Hispanic, Hispanic (any race), and Other Non-Hispanic. χ 2 tests assessed significance annually. Crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated comparing each group to White Non-Hispanic patients. Results: Among 5,979 pediatric appendectomy cases analyzed, Black Non-Hispanic patients consistently had the highest rates of prolonged LOS (37–51%), while White Non-Hispanic patients had the lowest (25–33%). Hispanic and Other Non-Hispanic patients demonstrated intermediate rates. Black Non-Hispanic patients had significantly higher odds of prolonged LOS in multiple years, including 2019 (OR 2.56, 95% CI 1.57–4.16). In 2022, Other Non-Hispanic patients also had significantly higher odds (OR 1.82, 95% CI 1.33–2.49). Conclusion: Significant and persistent racial and ethnic disparities in prolonged LOS were observed across all study years. These findings highlight the need for further investigation into underlying causes such as disease severity, healthcare access, and institutional practices contributing to these inequities. Click here to view the MISWeek 2025 Disclosure Index

Objective: Gastric volvulus is a rare and potentially fatal condition involving the rotation and obstruction of the stomach. This condition is classified based on timeframe, etiology, and the axis of its rotation. It is often a secondary pathology to a hiatal hernia. This case demonstrates the importance of rapid intervention and emphasizes the need for a high index of clinical suspicious, especially in patients who do not present with Borchardt’s triad. Delay in the care can lead to fatal consequences. Methods and Procedures: A 55-year-old female with a past medical history of a hiatal hernia who recently completed H. Pylori triple therapy, presented to the emergency department with a 3-day history of worsening nausea and nonbloody emesis, epigastric and flank pain, and no bowel movement for 5 days. CT scan demonstrated a large hiatal defect with gastric contents superior to the diaphragm. Results: The patient underwent robotic paraoesophageal hernia repair. The stomach was detorsed and reduced into the peritoneal cavity. The crus were then dissected from the hernia sac. The hernia sac was then reduced as well. Repair of the posterior crus was made with self-locking sutures and the repair was reinforced with a self-fixating absorbable mesh. Patient had no complications from the operations. Conclusion: Surgical intervention remains the first-line treatment for gastric volvulus, with minimally invasive techniques demonstrating reduced morbidity and length-of-stay for patients. Clinical suspicion must remain high in patients with abrupt abdominal pain, due to the variability in symptomology and difficulty with interpretation of imaging studies.

★ Honorable Mention: Harrith M. Hasson Award for the Best Presentation Promoting Education or Training The objective of this research is to obtain a three-dimensional translation of the action of robotic instrumentation preserving all the functions of multiport robotic surgery into a single site procedure. The method of this study was to use the existing mechanism in robotic surgery of a remote center as a basis for a mechanical concept to apply a unique geometry of prototypic instruments able to transfer all the functions of instrumentation using a single instead of multiple incisions. Because of this study the single site instruments would be able to preserve all the functions of a multiport instrument access. The preliminary indication is that the reduction of number of incisions does not have the negative impact on a mechanical dexterity of the robotic instrumentation.

Objective: To highlight a complex dissection of deep infiltrating endometriosis with bowel involvement in a fertility-preserving manner. Methods and Procedures: This is a video case presentation of a 30 year old G0 patient who presented with a longstanding history of pelvic pain, dysmenorrhea, dyspareunia, and dyschezia in the setting of endometriosis. Pelvic imaging demonstrated extensive endometriotic disease involving the retrocervical and retrouterine regions with evidence of infiltration of the anterior wall of the rectum and extension to the adnexal region. The ovaries were medialized and contained multiple endometriomas and hemorrhagic cysts. The patient desired surgical management due to the severity of her symptoms, as well as fertility preservation. The decision was made to proceed with robotic-assisted endometriosis excision and cystectomy with possible bowel resection. Results: At surgery there was significant adhesive disease noted from the posterior wall of the uterus to the sigmoid colon and rectum. The bilateral ovaries were medialized and adhered to the posterior uterus. Significant endometriotic disease was present involving the bilateral ovaries and invading the anterior wall of the rectum. After extensive adhesiolysis to separate the anterior wall of the rectum from the posterior uterus, left salpingo-oophorectomy was performed, followed by myomectomy, right ovarian cystectomy, and low anterior resection with colorectal anastomosis. The patient was discharged on postoperative day 6. She was initiated on Elagolix for further endometriosis suppression. At her postoperative visit, the patient was doing well and meeting all postoperative milestones. Conclusion: Minimally invasive surgical management of deep infiltrating endometriosis can be effectively completed in a fertility-preserving manner.

Objective: The adoption of artificial intelligence (AI) in surgical robotics is at an early stage, with AI-enabled technologies showing potential to enhance surgical precision, decision-making, and automation. Despite the widespread perception that AI is already transforming surgery, its actual implementation in robotic-assisted surgery remains limited. This study examines the current landscape of AI in surgical robotics presence in FDA-approved AI-enabled medical devices, and explores future directions for AI-driven advancements in robotic surgery. Method: A comprehensive analysis was conducted using the U.S. Food and Drug Administration (FDA) AI/ML-enabled medical device database to determine the distribution of AI applications across different medical fields. The presence of AI-enabled robotic surgery systems was specifically examined. Additionally, analysis was performed to evaluate the adoption of AI in surgical robotics relative to other industries. Results: AI adoption in surgical robotics remains minimal compared to other medical fields. The majority (76.1%) of AI-enabled devices are in radiology, while AI-integrated surgical robotics represents only a small fraction of approved medical devices. These findings highlight a significant gap between the perception and reality of AI integration in robotic-assisted surgery. Conclusion: AI has the potential to revolutionize surgical robotics, its real-world application is still in its infancy. A broader effort is needed to validate AI-driven surgical technologies objectively and to develop AI systems capable of cognitive assistance, workflow adaptation, and autonomous decision-making. Future research should focus on bridging the gap between surgeon expectations and the actual state of AI integration in robotic surgery.

★ Best Multispecialty Video Objective: To demonstrate the feasibility and safety of transanal specimen extraction during robotic low anterior resection (LAR) for recurrent diverticulitis in a patient concurrently undergoing ventral hernia repair with mesh. Methods and Procedures: This is a case of 40-year-old male with a past medical history of recurrent diverticulitis resulting in multiple hospitalizations and a symptomatic ventral hernia who presented to the hospital with an acute exacerbation one week prior to his scheduled surgical date. He underwent a robotic low anterior resection with transanal specimen extraction, lysis of adhesions with takedown of an enterocolic fistula, and a robotic ventral hernia repair with mesh. A technique for transanal specimen extraction was successfully implemented in this setting. Results: Transanal specimen extraction was achieved without intraoperative complications. The patient had an uneventful postoperative course with early return of bowel function, prompt advancement of diet, and timely discharge. Final pathology revealed diverticulitis with pericolonic abscess, fibrosis, serosal adhesions, and multinucleated giant cell reaction. Conclusion: This case demonstrates the successful application of transanal specimen extraction during robotic LAR, facilitated by enhanced pelvic visualization and access inherent to the robotic platform. Benefits of this approach may include reduced hospital stay, lower risk of postoperative complications, and improved cosmetic outcomes by avoiding an abdominal extraction incision.

Objective: A pelvic kidney is a rare congenital renal anomaly that occurs due to failure of kidney ascent from the pelvis during the 9 th week of embryogenesis. This anatomic variation can complicate pelvic surgery. This video will review pelvic kidney, retroperitoneal masses, and illustrate surgical technique for robotic hysterectomy in the setting of pelvic kidney. Methods and Procedures: A total robotic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, lysis of adhesions, and dilation and curettage were performed for treatment of postmenopausal bleeding. Results: The estimated blood loss was 5 milliliters, there were no complications, and the patient was discharged home same-day. Conclusion: Pelvic kidney is an important anatomic variation to distinguish when encountering a retroperitoneal mass. Hysterectomy is safest performed with concomitant ureterolysis and identification of retroperitoneal anatomy.

Objective: Present surgical challenges and techniques due to solid adnexal pathology obliterating the posterior cul de sac. Methods and Procedures: 38-year-old G1P1 who presented for acute on chronic pelvic pain, severe dyschezia associated with presyncopal episodes and worsening heavy menstrual bleeding admitted for sepsis. CT abdomen and pelvis demonstrating a bulky fibroid uterus measuring 18 × 8 cm with degenerative features. Infectious work-up was negative. After 5 days of empiric IV antibiotics she had persistent fever and worsening leukocyte. Results: Patient underwent a robotic-assisted TLH and bilateral salpingectomy. She was found to have a right ovarian solid mass occupying the entire posterior cul de sac with surrounding inflammation. Right partial oophorectomy was performed and final pathology was consistent with a benign right ovarian fibroma. The patient was discharged home on postoperative day two and had no postoperative complications. Conclusion: Ovarian fibromas are the most common benign solid tumors of the ovary. Diagnosis can be challenging to make preoperatively as they often resemble uterine fibroids. Degeneration of ovarian fibromas can lead to ischemia, hemorrhagic necrosis, and severe inflammation. Severe dyschezia is rarely reported symptom but can occur when it obliterates the posterior cul de sac. Surgical resection is safe and feasible in young premenopausal women. Our case demonstrates surgical principles of early anterior colpotomy, retroperitoneal dissection and ureter identification, and adnexal mobilization.

Introduction: Although barium is nonirritating to the gastrointestinal mucosa, it can cause the issue of appendicitis when an occlusive barolith is formed. We report a case of acute appendicitis from retained barium requiring robotic appendectomy two weeks after a barium enema. Case Report: A middle-aged woman with a history of irritable bowel syndrome, presented with right sided abdominal pain and nausea. Imaging revealed a dilated sigmoid colon with questionable malrotation, and a sigmoidoscopy was performed. A preoperative barium enema was completed, for which she presented again two weeks later with right lower quadrant pain, nausea, vomiting, and leukocytosis. Computed tomography imaging was suggestive of appendicitis due to a retained barolith, and she underwent robotic appendectomy. Discussion: Historically, retained barium was not considered clinically significant, but rarely it has been shown to cause appendicitis. A barolith is a rare mass formed from thickened barium sulfate mixed with feces, occasionally seen after gastrointestinal imaging with barium studies. Because barium sulfate is insoluble, it can occasionally precipitate in the bowel and, in rare instances, cause symptoms—particularly if it blocks the appendiceal orifice. Barium enema studies show that the appendix fills with contrast in at least 77% of cases, but only a small fraction, between 0.11% to 3%, of these cases go on to develop appendicitis. Conclusion: Patients undergoing barium studies should be informed of this potential complication and advised to seek immediate medical attention if abdominal pain occurs. Though this entity is quite rare and may result in delayed diagnosis, prompt evaluation can prevent significant consequences.

Objective: This work aims to develop smart laparoscopic tools equipped with advanced optical sensing and deep learning algorithms to enable real-time identification of critical anatomical structures. The primary goal is to enhance surgical decision-making by detecting blood vessels and ureters—even when these structures are obscured from the laparoscopic field of view or lie beneath the tissue surface. Methods and Procedures: A compact linear imaging system with custom-trained deep learning algorithms for tissue classification is embedded directly into standard laparoscopic tools, enabling detection at the point of contact without requiring external imaging systems. Preclinical testing was conducted using in vivo porcine models to evaluate the system's detection accuracy. Results: The smart tools demonstrated the ability to distinguish between blood vessels and ureters. Importantly, the system achieved a depth of detection exceeding 5 mm, surpassing current intraoperative imaging modalities, which are typically limited to 2–5 mm. These results highlight the capacity to identify hidden or obscured structures without the use of dyes or contrast agents. The system is also compact and cost-effective, making it suitable for single-use applications in MIS. Conclusion: The smart tools introduce a transformative approach to surgical safety and precision by embedding optical and AI-driven tissue identification directly into tools. The ability to provide deeper tissue assessment and maintain a standard tool profile supports broad applicability across surgical specialties. Future developments focus on integrating with robotic platforms; expanding detection to additional structures such as bile ducts, lymph nodes, and malignant tissues; and enhancing functionality for training and semiautonomous surgical workflows.

Objective: In anatomical liver resections, the main hepatic veins are important landmarks on the transection plane. We introduced and performed hepatic parenchymal transection along the main hepatic veins robotic liver resection (RLR). Patients and Procedures: From Oct 2022 to Feb 2025, we performed the robotic liver resection (RLR) in 69 cases. Anatomical RLR were undergone in 31 cases (mono-segmentectomy in 22, posterior sectionectomy in 4, anterior sectionectomy in 2, left hepatectomy in 2, median sectionectomy in 1). The clinical outcomes of RLR were evaluated by comparison of those of laparoscopic anatomical liver resection (LLR:n = 10) retrospectively. Our procedure in RLR: In anatomical resections, the hepatic parenchymal transection was performed from the root of the major hepatic vein as possible. Especially, we usually perform the cranio-ventral approach from the root of MHV in the series of right sided anatomical rection requiring cutting Cantlie’s line in combination with ICG fluorescence-guidance. This procedure can contribute to avoid the injury of hepatic vein and disorientation in the way of transection. As a result, precise anatomical RLR can be achieved safely and reliably. Result: Although there was no significant difference in the operation time between RLR and LLR (413 vs 409 min.; p = 0.95), the mean intraoperative blood loss in RLR was significant lower than that in LLR (102 vs 326 ml; p = 0.047). We experienced no posthepatectomy liver failure and biliary complication in this series. Median hospital stay after surgery was 9 days. Conclusion: Anatomical RLR using hepatic vein guided method can be completed very safely and precisely reducing the intraoperative blood loss.

Objective: Present surgical techniques for a robotic-assisted and hysteroscopic approach localization and excision of isthmocele. Methods and Procedures: 42-year-old G3P1101 who presented for secondary infertility following multiple failed IUI and IVF cycles. She also reported persistent abnormal intrauterine fluid. Pelvic MRI demonstrated thinning of the anterior myometrium to 5 mm, with a posterior myometrial thickness of 1.5 cm. She had a history of cesarean section and a prior hysteroscopic isthmocele resection in 2022. On hysteroscopic evaluation by reproductive endocrinology, a small residual isthmocele was visualized. Results: The patient underwent a combined laparoscopic and hysteroscopic isthmocele repair. The vesicovaginal space was dissected with traction on the peritoneum and both blunt and sharp dissection, carefully avoiding the uterine vessels. Intraoperatively, the defect was localized using hysteroscopic transillumination. The isthmocele was excised, and a two-layer closure was performed using barbed suture. The peritoneum was closed over the repair to reduce adhesions. The Foley catheter was removed on postoperative day six, and the patient was discharged without complications. Conclusion: An isthmocele is a cesarean scar defect that has become increasingly prevalent with rising cesarean delivery rates. Preoperative diagnosis can be challenging, particularly in patients with nonspecific symptoms such as abnormal uterine bleeding, pelvic pain, or infertility. Residual myometrial thickness <3 mm requires careful surgical planning. Surgical correction offers a safe and effective solution for symptomatic patients, particularly those desiring future fertility. This case highlights the advantages of a combined laparoscopic and hysteroscopic approach, which allows for precise defect localization, robust layered closure, and preservation of the endocervical canal.

★ Honorable Mention: Carl J. Levinson Award for Best Video Objective: To illustrate the challenges associated with diagnosing and managing an ectopic pregnancy in a patient with a previously undiagnosed Müllerian anomaly. Methods and Procedures: A 20-year-old female initially presented to the emergency department with abdominal pain in the setting of a positive home pregnancy test. She was discharged home with the diagnosis of a pregnancy of unknown location and advised to follow-up with her OBGYN. Unfortunately, she was lost to follow-up until two weeks later, when she returned with worsening symptoms, and imaging suggested a left ectopic pregnancy. Given concerns regarding her adherence to medical management, surgical intervention was pursued. Intraoperative findings revealed a left adnexal mass concerning for the ectopic pregnancy, leading to a left salpingectomy and left adnexal mass removal. However, surgical pathology showed no evidence of chorionic villi and instead revealed tissue consistent with a unicornuate uterus with left uterine remnant. The patient was ultimately diagnosed with an ectopic pregnancy in the contralateral fallopian tube, which responded appropriately to medical management with Methotrexate. Results: The presence of a Müllerian anomaly contributed to diagnostic uncertainty and an atypical pregnancy presentation, leading to the need for multiple surgical interventions and a combination of medical and surgical management strategies. Conclusion: This case underscores the critical role of Müllerian anomalies in complicating pregnancy location and management, as congenital uterine malformations can predispose patients to abnormal implantation and diagnostic uncertainty. A multidisciplinary approach, including thorough imaging, timely intervention, and careful follow-up, is essential for optimizing outcomes in such cases.

★ Paul Alan Wetter Award for Best Multispecialty Scientific Paper Objective: Augmented Reality (AR) and Virtual Reality (VR) systems offer promising new tools for preoperative surgical planning by enabling surgeons to interactively explore patient-specific anatomy. Our objective is to develop a synthetic MRI generation pipeline from standard abdominal CT scans and integrate these volumes into an immersive VR environment to enhance preoperative visualization, particularly when MRI is not available. Methods and Procedures: Building on our previous work synthesizing breast MRI from mammograms using deep learning models, we applied a CycleGAN-based model to generate synthetic MRI images from abdominal CT scans. A previously validated medical segmentation model, SAM-Med2D, was used to automatically label and outline key abdominal structures. The segmented volumes were then integrated into a VR platform. A desktop-accessible version was also developed to offer additional versatility. Results: This project represents a proof-of-concept application of combining synthetic imaging and virtual reality exploration for abdominal surgical planning. To our knowledge, this specific approach has not been previously reported. A basic VR prototype was developed, allowing users to manipulate and explore anatomical structures interactively. Ongoing work focuses on refining the imaging pipeline, improving segmentation accuracy, and enhancing the VR environment. Conclusion: This synthetic MRI and VR platform offers a novel approach to improving preoperative planning in abdominal surgery, especially when MRI is not readily available. By providing surgeons with immersive, patient-specific anatomical models, this technology has the potential to enhance surgical precision and reduce operative risks. Future work will focus on validation studies and refinement for clinical integration.

Background: Appendicular perforation (AP) complicates acute appendicitis, increasing morbidity and resource use. Despite improved early diagnosis and management outcomes, the outcomes and advantages of minimally invasive surgeries (MIS) remain underexplored. Methods: Using the NRD dataset (2018–2022), 60,997 adults with perforated appendicitis undergoing MIS admitted to metropolitan hospitals were analysed. The cohort was dichotomized into: Laparoscopic group (LG, n = 60,258) and Robotic group (RG, n = 739). Demographics, clinical characteristics, and 30-day readmissions were assessed using standard statistical tests. Readmissions were calculated using the NRDVisitlink, which connects specific patient IDs. Results: RG were older, with higher private insurance, Medicare rates, and sicker patients (50% Abscess) than LG. RG had worse comorbidities (higher Elixhauser scores) and more elective admissions (10% more), with 1.8x higher hospital costs. Morbidity and mortality were similar, but RG required more postdischarge care (10% vs. 7%). 30-day readmissions were also similar, with surgical site infection as the most common cause. RG procedure rates and hospitals performing them have increased in recent years. Logistic regression showed readmission odds were similar for MIS procedures. Readmission was lower in nonteaching hospitals, females, older patients, those with fewer comorbidities, on mechanical ventilation, and with lower stroke/bleeding rates. Extended hospital stays did not correlate with a reduction in readmission rates. Conclusions: RG procedures are increasing with similar outcomes to LG. Despite higher costs due to sicker patients and elective admissions, no increased morbidity, mortality, or readmissions make RG a valuable option for select patients.

Objective: Retrospective study of 10 year consecutive cases of endometrial ablation performed by the author by several different methods. This study will show a small percentage of cases developed hematometra no matter the experience of the author or the methods used. Methods and Procedures: The past 10 years consecutive cases of endometrial ablation were evaluated by chart review for postoperative presentation of cyclic pelvic pain, amenorrhea/hypomenorrhea. Symptomatic patients were further evaluated by pelvic ultrasound. Some required MRI of the pelvis for complex findings by ultrasound. Surgical resolution was achieved by ultrasound guided cervical dilatation and lysis of intrauterine adhesions. A few required surgical intervention of hysteroscopic evacuation of hematometra and endometrial biopsy. One required hysterectomy by request. Results: 200 cases had chart review. 10 patients (5%) have had chronic hematometra requiring repetitive evacuation, either by ultrasound guided dilatation of cervix and lysis of intrauterine adhesions, or hysteroscopic surgical intervention. One patient requested hysterectomy. The types of hematometra encountered were mostly central. One patient had a large cervical hematometra measuring 6 cm, which was drained in the office by dilating the cervix under ultrasound guidance (twice over two years). Conclusion: Hematometra can be a complication after Endometrial Ablation causing cycling pelvic pain even with amenorrhea/hypomenorrhea. This becomes a dilemma in patient management requiring further intervention. The etiology of hematometra though rare, is not entirely method or surgeon dependent but could be due to patient's quality of tissues and menopausal status. Prevention of hematometra will be discussed.

★ Gustavo Stringel Award for Best Poster by a Resident Objective: To identify factors associated with duration of postanesthesia care unit (PACU) stay after minimally invasive hysterectomy. Methods and Procedures: A retrospective chart review was conducted including patients who underwent scheduled minimally invasive hysterectomy with Minimally Invasive Gynecologic Surgical Specialists with a same-day discharge between Jan 2023 and Jun 2024. Electronic medical records were reviewed for demographics, medical history, intra-operative variables, and postoperative outcomes. Data was analyzed using Pearson correlation coefficient, Wilcoxin rank sum, and Kruskal-Wallis tests. Results: Longer PACU stays were significantly associated with self-reported presence of postoperative pain (4.6 vs 4.1 hours, p = 0.04), uterine weight >500 g (4.7 vs 4.1 hours, p = 0.01), and nonsmoking status (3.3 vs 4.3 hours, p = 0.05. Other variables including age >60, anemia, obesity, ASA score, prior abdominal surgery, preoperative diagnosis, afternoon start time, surgery duration, additional procedures, EBL >200 mL, intraoperative complications, mini-laparotomy, and postoperative nausea were not significantly associated with PACU stay (all p > 0.05). Conclusion: Postoperative pain, uterine weight >500g, and nonsmoker status were independently associated with longer pacu stays. Consistent with prior studies, smoking was associated with a shorter PACU stay, however this finding may be influenced by reporter bias and the small number of reported smokers (14/384). Interventions aimed at improving pain control and prioritizing patients with larger uteri earlier in the surgical schedule may reduce PACU stay and facilitate earlier discharge home, ultimately reducing the burden to the hospital system.

Objective: The objective of the study was to assess the outcome of robot-assisted radical hysterectomy in cervical cancer stage IB1. Methods and Procedures: This is a retrospective study of patients with cervical cancer stage IB1 who surgically treated by robot-assisted radical hysterectomy. All patients underwent type C radical hysterectomy according to the Querleu-Morrow classification. All patients underwent the no-look, no-touch technique to avoid tumor spillage. After surgery, adjuvant radiotherapy was selectively implemented according to the Sedlis criteria Oncologic outcomes of the patients were evaluated. Results: A total of 29 patients were included in the final analysis. Median follow-up time was 50 months. There was one recurrence (3.4%) in the cohort at the time of analysis. And there were no (0%) cancer-related death. Disease-free survival was 48.2 months and overall survival was 50 month. Conclusion: Robot-assisted radical hysterectomy could achieve satisfying therapeutic outcomes in patients with cervical cancer stage IB1. Further large-scale RCTs and clinical studies are required to provide relevant data. We expect to obtain the results of ongoing large-scale RCTs ( NCT03719547 , NCT04831580 ).

Objective: Robotic-assisted cystectomy (RAC) is currently representing 30% of all performed cystectomies. The common RAC device failures and clinical incidents were reviewed in the last 10 years. Methods: 396 reports were queried with the search term “Robotic assisted Cystectomy” from the Manufacture and User Facility Device Experience Database (MAUDE). Reports spanned between 01/01/2015 and 01/01/2025 and were categorized by different clinical presentation, device problems, and Gupta classification. Linear regression with R 2 value is reported for total case number trend. Results: RAC report increased over time (R 2  > 0.7) and peaked in 2022. Majority of cases were RAC with urinary diversion (52%) and for malignancy (70%). The most common device problems were failure in the staple line (12%), with 20% of laparoscopic and 80% of robotic staplers, trocar fragmentation (4%), and electrosurgical unit output problem (3%). 16% of staple line problems resulted in hemorrhage/bleeding and required for further intervention. 74% of cases were classified as Gupta 1 or 2 (required no/minor intervention), and 26% of cases were Gupta 3 or 4 (required major intervention or resulted in life-threatening/death event). About 5% of reported complications are related to the device malfunction during RAC and required for further intervention, and 1 case with “unintended system motion” resulted in conversion to open surgery and ICU admission. Four deaths (1%) were reported without identifiable device problems in those cases. Conclusion: By identifying the common device failures in RAC in the past decade, surgeons can improve patient safety, optimize surgical outcomes and taper patient expectations.

Objective: On average, it can take 7 years to receive a diagnosis of endometriosis. As definitive diagnosis can be made only with histological review, it is critical to perform a thorough survey of the abdomen and pelvis. This video guides the viewer through a standard process to laparoscopically examine each abdominopelvic organ. It also provides a pictorial review of the varying appearances of endometriosis for surgeon reference to aid in correctly identifying tissue abnormalities. Methods and Procedures: The video teaches how to perform a step-by-step abdominal survey via laparoscopy, including patient positioning, relevant anatomy in the upper abdomen and pelvis, and surgical technique. The varying appearances of endometriosis and common anatomic locations are also discussed in the video. Results: This video series can serve as a guide to developing surgeons as they work towards a more complete pelvic survey and improve their recognition of various atypical endometriosis appearances. Conclusions: Residents and surgeons in practice can utilize this survey and the reference photos to better identify endometriosis lesions and thus diagnose their patients with chronic pelvic pain.

★ Honorable Mention: Best General Surgery Scientific Paper Background: Colorectal cancer (CRC) is the third-leading cause of cancer-related mortality in men and the fourth in women in the United States. Combined, it is the second most common cause of cancer death, with an estimated 52,900 deaths anticipated in 2025. Although tobacco is a known carcinogen, regional trends in its usage and potential relationship with CRC incidence remain underexplored. North Carolina, a state with historically high tobacco use, provides important context for examining trends across demographic and geographic groups. Methods: This study utilized data from the North Carolina Data Portal, Behavioral Risk Factor Surveillance System (2019–2023), and State Cancer Profiles (2016–2020). Tobacco use prevalence was summarized by year, sex, and race/ethnicity. Age-adjusted CRC incidence rates (per 100,000 population) were compiled by county and demographic subgroups. Descriptive comparisons explored patterns in areas with high tobacco use and CRC incidence. Results: Tobacco use remained high across North Carolina in 2023, with a statewide average of 77.2%. Hispanic individuals reported the highest usage (81.8%), followed by Non-Hispanic Black (77.8%) and White (76.4%) populations. Interestingly, despite higher tobacco use, the Hispanic population experienced lower CRC incidence (27.1 per 100,000) compared to Non-Hispanic Black residents, who had both elevated tobacco use and the highest CRC incidence (38.1 per 100,000). CRC incidence was higher in counties such as Granville (47.1), Rutherford (45.3), and Cleveland (45.9). Conclusion: Despite higher tobacco use, Hispanic individuals exhibit lower CRC incidence compared to Non-Hispanic Black populations. This suggests protective lifestyle or environmental factors in Hispanic communities that may inform future preventive strategies.

★ Honorable Mention: Carl J. Levinson Award for Best Video Objective: To describe a robotic-assisted deep inferior epigastric perforator (DIEP) flap breast reconstruction using a novel transverse posterior fascial incision and to assess its feasibility, donor-site morbidity, and reconstructive outcomes in a multidisciplinary setting. Methods and Procedures: A 43-year-old female with ductal carcinoma in situ (DCIS) underwent a right-sided mastectomy with immediate prepectoral tissue expander placement. She was considered an excellent candidate for DIEP flap reconstruction based on preoperative perforator anatomy. During the reconstruction operation, the DIEP flap was raised in the left hemi-abdomen and the target perforator was dissected by tracing the vessels posteriorly through the rectus muscle. The surgical robot was then docked by the minimally invasive team for intraabdominal dissection. A transverse posterior fascial defect was created, and the left inferior epigastric vessels were dissected robotically along the rectus muscle and divided from the external iliac artery. The pedicle was exteriorized without complication. The anterior fascial defect (∼1 inch) was closed primarily. The flap was then anastomosed to recipient vessels in the right chest by the plastic surgery team. Results: The procedure was completed without intraoperative complications. The flap was fully mobilized, and postoperative recovery was notable for preserved abdominal wall integrity, decreased pain, and no evidence of hernia. Operative time was approximately 7 hours. Conclusion: This case highlights a successful robotic DIEP flap reconstruction using a posterior fascial approach, which allows dissection away from the vascular pedicle thus eliminating the need for a traditional 12–15 cm fascial incision and reducing the risk of hernia, abdominal wall weakness, and chronic donor-site pain.

Objective: Laparoscopic cholecystectomy remains the gold standard for gallbladder disease; however, the optimal dissection technique—ultrasonic versus electrocautery—remains controversial. Ultrasonic dissection has been proposed to reduce perioperative complications, yet supporting evidence is limited. This meta-analysis evaluates its efficacy and safety compared to electrocautery. Methods and Procedures: Databases (PubMed, Embase and the Cochrane Library) were searched until Dec 2024 for randomized controlled trials (RCTs) that compared these techniques. Meta-analyses were conducted using risk ratios (RR), mean differences (MD), and standardized mean differences (SMD) with 95% confidence intervals (CI) using random-effect models. Results: From 659 studies, 33 RCTs comprising 4,061 patients were included. Ultrasonic dissection was associated with increased gallbladder perforation (RR = 4.57; 95% CI [2.65–7.89]; p = 0.0008), bile leakage (RR = 1.76; 95% CI [1.20–2.58]; p = 0.01), and postoperative drainage requirements (RR = 2.24; 95% CI [1.29–3.91]; p = 0.01). However, it reduced operative time (SMD = 1.07; 95% CI [0.62–1.51]; p < 0.0001), intraoperative blood loss (SMD = 1.12; 95% CI [0.32–1.92]; p = 0.01), postoperative pain at 24 hours (MD = 0.68; 95% CI [0.18–1.17]; p = 0.01), and hospital stay duration (MD = 0.27; 95% CI [0.11–0.43]; p = 0.004). Other outcomes showed mixed findings. Conclusions: Ultrasonic dissection enhances surgical outcomes by reducing blood loss, postoperative pain, and hospital stay, but it is associated with higher rates of gallbladder perforation and bile leakage. Further high-quality RCTs are warranted to establish its role in routine practice.

Objective: We have found that significant weight loss with compromised crural integrity leads to hiatal hernia and recurrence. This often manifests as GERD and dysphagia. We demonstrate a novel robotic-assisted technique that remodels the diaphragmatic crus with circumferentially wrapped nonpermanent reinforced tissue matrix (RTM). The contralateral crus is buttressed with pledgets and primary crural closure is optimal. Methods and Procedures: This technique involves hernia reduction, sac excision, and esophageal mobilization. The attenuated diaphragmatic crus is then reinforced by folding RTM circumferentially around it, secured with running suture. Pledgets are applied to the contralateral crus, preventing suture injury to the muscle, and crura are approximated. This approach is useful, particularly in patients who have had significant weight loss. This technique has been evaluated through intraoperative performance and excellent short-term outcomes with complete symptom resolution. Results: Early clinical experience in a series of patients has demonstrated successful tension-free primary closure with remodeling of the crus using RTM, with no observed suture pull-through or RTM-related complications. We report improved confidence in closure, particularly in bariatric patients with friable crural tissue. The technique added minimal operative time and required no specialized instrumentation. Conclusion: Reinforcing attenuated diaphragmatic crura with RTM during hiatal hernia repair offers a simple, reproducible technique to improve muscle integrity with reconstruction and remodeling of the tissue and ease of robotic-assisted closure. This technique may enhance outcomes, especially in patients with compromised tissue integrity, and is readily adoptable.

★ Honorable Mention: Carl J. Levinson Award for Best Video Objective: This video serves as an example for alternative surgical approaches to ectopic pregnancies in patients that are not ideal candidates for transabdominal laparoscopic surgery. Methods: Our video includes a detailed case report of a 37-year-old G1 with history of midline vertical ventral hernia repair with mesh and BMI of 62, who presented for right tubal ectopic pregnancy and desired surgical intervention. Results: In this scenario, due to concern for complications in the setting of 8 cm midline incision and morbid obesity, pt was counseled for vNOTES approach to right salpingectomy with subsequent successful removal of ectopic pregnancy. Patient was discharged home on the day of surgery and on two week follow up reported no pain or complications. Conclusion: Although vaginal Natural Orifice Transluminal Endoscopic Surgery or vNOTES has been around for over a decade, it is still considered a relatively new procedure due to technical challenges and surgeon comfort. There have been proven benefits to this approach in obese patients with complex surgical history, including less need for Trendelenburg position, lower insufflation pressures, and improved postoperative pain scores. Studies have shown a steep learning curve with vNOTES; thus, inexperienced surgeons should be encouraged to utilize this approach. Further randomized clinical trials are indicated for comparison of risks and benefits in vaginal versus transabdominal approaches to common laparoscopic procedures in both complex and routine cases such as ectopic pregnancy.

Objective: To report a rare case of stage IV Intravenous Leiomyomatosis (IVL) presenting as intravascular thrombus extending to the right atrium, emphasizing the importance of early diagnosis and a multidisciplinary surgical approach. Methods and Procedures: A 37-year-old premenopausal woman presented with abdominal pain, nausea, and dizziness. Initial CT imaging revealed an intraluminal thrombus from the left renal vein into the right atrium. The Interventional Radiology team performed thrombectomy using ClotTriever and FlowTriever devices. Histopathology confirmed smooth muscle cells consistent with IVL. Subsequent imaging showed a uterine mass. The patient underwent robotic-assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, ureterolysis, retroperitoneal dissection, and excision of a 10 cm fibroid from the left uterine vein. Results: Thrombus pathology confirmed IVL, prompting discontinuation of anticoagulation. Imaging and gynecological evaluation revealed uterine fibroids. Posthysterectomy, the pathology confirmed benign leiomyoma with intravascular extension. The patient recovered well, with no postoperative complications or recurrence observed during follow-up. No anticoagulation was continued postoperatively due to the nonthrombotic nature of IVL. Conclusion: This case illustrates stage IV IVL mimicking a thrombus, with extension to the right atrium. A multidisciplinary strategy involving interventional radiology, vascular surgery, and gynecology enabled definitive diagnosis and successful treatment. Early recognition, histopathological confirmation, and comprehensive surgical excision are essential in preventing life-threatening complications in IVL. Tailored surgical planning, including retroperitoneal dissection and uterine artery control, can ensure optimal outcomes in complex presentations of this rare entity.

Introduction: A 61-year-old male with a longstanding history of GERD, dysphagia, and Barrett’s esophagus presented for surgical evaluation due to worsening reflux symptoms and unintentional weight loss. He was previously diagnosed with GERD and underwent endoscopic ablation for Barrett’s esophagus. Despite taking Omeprazole, his symptoms persisted. An EGD performed revealed LA grade D erosive esophagitis, a 4 cm sliding hiatal hernia, and a DeMeester score of 61.5 on day two of pH monitoring. Given his clinical profile, he was considered an appropriate candidate for robotic single-port hiatal hernia repair with partial (Toupet) fundoplication. Procedure: Under general anesthesia, the patient underwent single-port robotic surgery through a 1.2 cm incision at a preexisting scar site. The gastrohepatic ligament was divided, and a prominent accessory left hepatic artery was preserved. Dissection was carried up and down the right and left crura, with 8 cm of distal esophagus reduced into the peritoneal cavity. Posterior cruroplasty was completed with two V-Loc sutures. A Toupet fundoplication was constructed over a 52-French bougie, securing the posterior fundus behind the esophagus and anchoring the wrap to the esophagus and right crus. Intraoperative EGD confirmed proper positioning and tension of the fundoplication. Results: The patient had an uneventful hospital course and was discharged within 3 hours postoperatively without complications. Conclusion: Single-port robotic hiatal hernia repair with toupet fundoplication is a safe and technically feasible approach in appropriately selected patients.

Objective: Achalasia is a primary esophageal motility disorder caused by failure of the lower esophageal sphincter (LES) to relax with an estimated prevalence of 10 per 100,000 people. We present a case report of a 39-year-old male with an initial presentation of life-threatening massive aspiration on induction for an elective robotic inguinal hernia repair. Methods and Procedures: History, labs, imaging, pathology, and surgical intervention in a single patient with undiagnosed sigmoidal achalasia. Results: After airway stabilization with emergent tracheostomy and bronchoscopy, CXR obtained due to difficulty passing a nasogastric tube which showed a tubular structure in right chest with stomach bubble present in abdomen. hest CT revealed an 9.2 -cm sigmoidal megaesophagus extending from the LES to the cricopharyngeus. Patient underwent two endoscopies on subsequent days for combined total of seven hours to achieve disimpaction along with dilatation and botulinum toxin A injection. Esophagram was obtained showing the sine qua non “birds beak” as a baseline examination, and he then underwent a laparoscopic Heller myotomy with Dor fundoplication on hospitalization day 5. He was decannulated and discharged on hospitalization day 7 on a pureed diet and the remainder of his recovery was uneventful. Conclusion: Goal of this case report is to inform upon this unique presentation of achalasia and add to the otherwise scant literature on performing semiurgent/emergent laparoscopic Heller myotomy outside of those done for tracheal compression from mass effect in patients with known achalasia. We demonstrate that performing semiurgent/emergent laparoscopic Heller myotomy procedures can be a viable and safe.

Objective: This case report underscores the diagnostic and surgical challenges in managing a colo-ovarian fistula in a patient with subclinical diverticulitis. Methods and Procedures: A 36-year-old female presented with sudden-onset left lower quadrant pain that worsened with movement and improved with defecation and urination. Imaging revealed no evidence of obstruction and a stable complex cystic lesion in the left adnexa containing multiple air-fluid levels. A linear tract of rectal contrast extended from a diverticulum of the rectum to the adnexal collection, which contained a small amount of rectal contrast. The suspected abscess did not improve with antibiotic therapy and was inaccessible for percutaneous drainage, thus minimally invasive surgical management was achieved. Results: Following robotic-assisted left salpingo-oophorectomy and sigmoid colectomy with colorectal anastomosis, pathology of left ovary and fallopian tube revealed a 6 cm cystic cavity containing incompletely digested food and extensive fibroinflammatory changes. The sigmoid colon specimen showed marked diverticulitis with perforation. The patient remained asymptomatic at follow-up and resumed normal daily activities. Conclusion: Colo-adnexal fistulas are rare complications of diverticulitis, and their nonspecific presentation often resembles other pelvic pathologies, leading to diagnostic challenges and delays. These rare fistulas lack standardized diagnostic and treatment protocols, but surgical intervention is typically required for definitive management. Early recognition and a multidisciplinary approach are essential to improving outcomes in this complex condition.

Objective: Robot-assisted surgery is associated with enhanced postoperative recovery and refined instrumental features such as improved visualization, dexterity, and ergonomics. Several surgical robotic platforms are approved by the Food and Drug Administration (FDA). An advanced laparoscopy robotic system was approved by the FDA in 2017 and offers robot-assisted capabilities in comparison to conventional laparoscopy. The objective of this video is to highlight the robot-assisted hysterectomy approach, provide an overview of the advanced laparoscopy robotic system, and to discuss hysterectomy techniques using the advanced laparoscopy robotic system. Methods and Procedures: This is a surgical video recorded in a community teaching hospital operating room. The patients are a 47-year-old P2042 with abnormal uterine bleeding, fibroids, and history of multiple pelvic surgeries and a 52-year-old P3013 with chronic pelvic pain, fibroids, and 3 prior cesarean sections desiring definitive surgical management. Robot-assisted total laparoscopic hysterectomy was performed using the advanced laparoscopy robotic system. Hysterectomy techniques involved utilizing a triangular or diamond port configuration, dynamic use of the smart camera and port sites, and articulating the needle driver for colpotomy closure. Results: The two cases each had an estimated blood loss of 50 mL, no complications, and were discharged home on postoperative day one. Conclusion: The advanced laparoscopy robotic system offers a minimally invasive approach to hysterectomy that may offer advantages for the patient and surgeon. Techniques of varying port configuration, dynamic use of the smart camera, articulating the needle driver for colpotomy closure, and port hopping help illustrate this surgical approach.

★ Harrith M. Hasson Award for the Best Presentation Promoting Education or Training Objective: As concern increases over resident’s surgical numbers, there is a growing emphasis on developing laparoscopic skills outside of the OR. Previous studies support the role of laparoscopic simulation in the development of surgical skills. This video hopes to elucidate new laparoscopic training activities that would be accessible to all residency programs and offer new opportunities to grow laparoscopic skill. Methods and Procedures: A series of videos demonstrate different low cost box trainer activities including Sugar Cube Stacking, Rosemary Trimming, Brussel Sprout Peeling, Petal Pulling, Unsnapping Buttons, Cheerio stacking and Jelly Bean Sorting. Each video lists the items required and the goals for the resident performing the task. Results: This video series can serve as a guide to new and interesting laparoscopic training exercises that maintain resident interest and allow them to develop new skills outside of the OR. Conclusions: Residents can develop a variety of laparoscopic skills and techniques utilizing low cost activities as shown in this video. These exercises are a helpful adjuvant to the typical FLS training exercises and can be used for increased novelty in residency programs.

MULTISPECIALTY SCIENTIFIC PAPERS, VIDEOS & POSTERS Objective: Ovarian cancer is the leading gynecological malignancy. Recent findings indicating that high-grade serous ovarian cancer originates in the fallopian tubes, coupled with evidence that salpingectomy correlates with a reduced risk of developing ovarian cancer. The aim of the present study was to evaluate the feasibility and short-term complications associated with prophylactic salpingectomy in women aged 45 years or older undergoing elective cholecystectomy. Methods and Procedures: A total of 105 patients, of mean age 55 years and median parity 2, scheduled for elective laparoscopic cholecystectomy consented to concomitant prophylactic salpingectomy. Results: Salpingectomy was successfully completed in 98 (93.3%). In seven cases, the procedure could not be performed due to dense adhesions and scars that hindered access to or visualization of the fallopian tubes. Conclusions: While the results may not be generalizable, this study suggests that salpingectomy could be feasible during various laparoscopic procedures. It is essential for nongynecologists to inform patients scheduled for surgery of risks and benefits of this additional procedure. Implementing this will be an exercise in bridging surgical silos.

UROLOGY SCIENTIFIC PAPERS & POSTERS ★ Best Urology Scientific Paper Objective: We have been developing a demonstration platform for semiautonomous robotically assisted partial nephrectomy. While this project focuses on kidney tumor resection, the techniques we are developing are applicable to other operative procedures. We envision that supervised robotic execution of a surgical task, incorporating multimodality sensing, has the potential to improve tumor margins and consistency in clinical care. Methods and Procedures: Our demonstration platform consists of two robot arms, an RGBD video camera, a vacuum grasper, and a cautery device. Patient specific phantoms were created from CT data of cancer patients to include the kidney, surrounding tissue, tumor, and vasculature. To plan an incision path, an RGBD observation of the scene is fused with a segmented NIR image of kidney and tumor. A path planner calculates distances between kidney points and tumor points to identify a cutting path for robot execution. Results: We developed hydrogel kidney phantoms with fluorescence capability that imitates clinical negative staining. Fusing the RGBD and NIR images allows us to segment kidney and tumor. We conducted experiments using our dual arm robotic system to perform initial incisions marking the resection margin around tumors in hydrogel phantoms with fluorescence guidance, demonstrating feasibility. Conclusion: These phantom results are a step towards demonstrating these concepts in swine animal studies. We are developing a workflow with four steps: 1) preoperative planning based on CT imaging; 2) intraoperative planning and guidance based on real-time organ tracking and deformable modeling of the anatomy; 3) robotic path execution and adjustment; and 4) postprocedure evaluation of resection margins.

Objective: Healthcare is a major contributor of Canada’s green-house emissions, hospital operating-rooms represents a significant resource intensive sector due to high energy demands and waste production. The surgeon has an opportunity to provide leadership for environmental stewardship, through the concepts of sustainability – refuse, reduce, reuse, repurpose, recycle and collaborative team building. We investigated the reduction in carbon-foot print utilizing surgical tray optimization for pancreatectomy surgery. Methods and Procedures: Literature search reveals the carbon footprint for surgical instruments sterilization procedures, allowing environmental impact calculations for pancreas surgery. Tray optimization consolidates instruments into a specific pancreatectomy surgical instrument bundle. Nonessential surgical Instruments (utilized < 80% of cases) were culled from the surgical tray. Frequently used “peel-packed” instruments were added to the Pancreatectomy bundle. Results: Prior to optimization significant energy waste was identified due to the inefficient use of general surgery instrument trays sterilization process. Utilizing a 77 g CO2e per instrument in surgical trays and 189g CO2e for peel-pack instruments, carbon foot-print saving was assessed. Pancreatectomy surgical tray optimization reduced instruments from 144 to 76 instruments/pancreatectomy. Over 1 year ∼ 100 procedures is estimated to reduce the carbon foot-print, saving almost 1 ton of CO2e and $40,000 per year, the equivalent of driving 3500 km in a gas powered vehicle. Conclusion: Surgical tray optimization demonstrates an area readily available to surgeons, interested in initiating a practical approach to climate action leadership in the operating room. Reduction in CO2e from waste due to surgical instrument sterilization across Fraser Health Authority, could support the health system’s move to organizational sustainability.

Objective: The pelvic plexus, pelvic splanchnic nerves, and superior hypogastric nerve are crucial for bladder and bowel function, arousal, and lubrication. Damage to these nerves during endometriosis surgery can result in postoperative voiding dysfunction, with reported incidence rates ranging from 1.4% to 29%. This study aims to highlight the importance of nerve-sparing techniques in endometriosis surgery to preserve pelvic function and improve patient outcomes. Methods and Procedures: We present the case of a 43-year-old nulliparous patient with primary infertility, dysmenorrhea, heavy menstrual bleeding, and dyspareunia, who underwent nerve-sparing surgery following failed medical treatment. The surgical approach focused on meticulous dissection to preserve the pelvic autonomic nerves, as demonstrated in our video. Results: Postoperatively, the patient did not experience voiding dysfunction or other neurological complications. The preservation of pelvic nerve integrity contributed to symptom relief and an overall improvement in quality of life. Conclusion: Nerve-sparing techniques in the surgical management of endometriosis can effectively prevent postoperative voiding dysfunction and preserve pelvic autonomic function. This case supports the importance of integrating nerve-sparing approaches to enhance patient outcomes and quality of life following endometriosis surgery.

Objective: Analyze the risk of vaginal or perineal laceration at the time of time of total hysterectomy in patients using testosterone. Methods and Procedures: A retrospective review was conducted of all minimally invasive total hysterectomies performed by benign gynecologic surgeons at a single academic hospital from May 2015 through 2020. Testosterone use was defined as any use within one year prior to surgery. Operative notes were used to determine if a laceration occurred. χ 2 testing and odds ratios (OR) were used to compare testosterone users with controls. Results: A total of 799 patients were identified, 39 of whom sustained lacerations. Patients using testosterone were more likely to sustain a laceration (7 of 41) than controls (32 of 758) (OR: 4.67, CI 95% [1.92–11.34], p = 0.0007). Across cohorts, additional factors were identified as risks: morcellation of specimen (OR: 5.83 [2.96–11.49], p < 0.001), uterine weight greater than 250 grams (OR: 4.14 [2.15–7.96], p < 0.0001), largest uterine dimension greater than 20 cm (OR: 4.88 [1.34–17.85] p = 0.0165), largest fibroid dimension greater than 5 cm when fibroids were present (OR: 8.57 [3.36–21.64], p < 0.001), subspecialist surgeon (OR: 3.26 [1.60–6.50], p = 0.0011). Other factors were identified as protective: at least primiparity (OR: 0.21 [0.10–0.45], p < 0.0001) and sexual activity with vaginal intercourse (OR: 0.16 [0.07–0.36], p < 0.001). Importantly, some risk factors were more common in the testosterone group. Conclusion: Patients taking testosterone are at a higher risk of vaginal or perineal laceration at the time of hysterectomy. Likely there is a complex relationship between multiple risk factors that contribute to that risk.

Objective: Guillain-Barré Syndrome (GBS) is an acute, autoimmune polyneuropathy that can lead to weakness and paralysis. Although multisystem effects of GBS have been studied, the role of GBS in herniation remains overlooked. We present a case of a patient with long-term complications of GBS leading to abdominal wall laxity and the development of a Spigelian hernia, underscoring GBS as a cause of eventration of the abdominal wall. Methods: This is an observational case report with retrospective chart review of one patient at a single academic hospital. Results: 45-year-old female with a PMHx of GBS and PSH of C-section and Spigelian hernia repair presents with persistent RLQ abdominal pain and swelling. Patient continues to experience recurrent swelling, pain, and a visible abdominal wall protrusion. Physical examination revealed laxity in the RLQ with neuromuscular deficits. Patient’s presentation is consistent with progressive abdominal wall laxity due to Spigelian hernia, possibly secondary to GBS-related nerve damage. The abdominal binder did not provide adequate support and caused discomfort. Given the lack of nonsurgical options, a surgical approach was discussed. Patient will undergo a diagnostic laparoscopy and abdominal wall reinforcement with mesh. Conclusion: This case highlights the potential role of GBS-induced neuromuscular dysfunction in contributing to a Spigelian hernia. Nerve damage caused by Guillain-Barré Syndrome can cause structural defects in the abdominal wall, leading to hernias.

Introduction: Spontaneous diaphragmatic hernia is a rare form of a diaphragmatic hernia. Literature on diagnosis, pathophysiology, and management is sparse. We report, to our knowledge, the first transabdominal approach of a spontaneous diaphragmatic hernia repair with a robotic platform. Methods and Procedures: A 55-year-old male presented to the emergency department with left sided chest pain. Computed tomography (CT) showed air-fluid levels in the left lower lung base that was initially diagnosed as a lung parenchymal abscess. After 10 days without improvement on IV antibiotics, repeat CT was conducted which demonstrated gastric mucosa above the diaphragm indicating the diagnosis of a spontaneous diaphragmatic hernia. General surgery was consulted, and a transabdominal approach was chosen due to the patient’s significant pleural effusions and the surgeon’s experience. Results: During the surgery severe adhesions and dense debris required careful dissection which prolonged the operative time. The stomach was then reduced back into the abdominal cavity. The strangulated section was removed, and the diaphragmatic defect was repaired using sutures and fibrin sealant. The patient required a thoracoscopy on postop day 2 with a washout because of the pleural effusion not resolving in a timely manner. Conclusion: Patients with spontaneous diaphragmatic hernias often present with nonspecific signs and symptoms making preoperative diagnosis difficult. Once diagnosed, surgical management is either transthoracic, transabdominal, or a combined approach. This case demonstrates a morbidity and operation time benefit in patients, compared to a combined approach in those with significant pleural effusions.

GENERAL SURGERY SCIENTIFIC PAPERS, VIDEOS & POSTERS Objective: We operated on a series of mostly obese early elderly/elderly cases with ventral hernias, including ones with large-giant/massive and multiple widely-spaced types using the sutureless “Slim-Mesh” technique to repair them. Other objectives include decreasing surgical time and intra- and postoperative complications. Methods and Procedures: At our Department, between Oct 2010-Mar 2024, 61 early elderly/elderly cases with ventral hernias were operated on with the “Slim-Mesh” technique. We divided our cases into “early elderly” (65–74 years) and “elderly” (≥ 75 years). A ventral hernia was small-medium, or large-giant/massive when its diameter measured 2–9.9 cm, 10–14.9 cm-15–19.9 cm/≥ 20 cm respectively. This was a prospective (81%)-retrospective study. Results: We treated 38 females and 23 males. Mean age was 74-years old and 51% of cases were obese. The “early elderly” group comprised 36 cases; the “elderly” group 25. Small-medium (56%), large-giant/massive (44%), and multiple widely-space ventral hernias (5%) were found intraoperatively in 34, 25/2, and 3 cases respectively. Overall mean surgical time was 98 minutes. Mean length of hospital stay was 2 days, and mean follow-up time 6 years. We had 7 late postoperative-complications: 2 (3%) hernia recurrences, and 5 trocar-site hernias. Conclusion: The sutureless “Slim-Mesh” technique reduces surgical time and intra-and postoperative complications, promoting laparoscopic ventral-hernia repair over open surgery or traditional transfixation suture-based laparoscopy in both elderly populations, including ones with large-giant/massive and multiple widely-space ventral hernias, even in elderly obese cases. “Slim-Mesh” proved to be safe, straightforward, quick, easy-to-reproduce and economical.

Objective: Acute appendicitis is the most common surgical emergency worldwide. Postcolonoscopy appendicitis is an exceedingly rare complication, reported to occur in 3.8 per 10,000 colonoscopies. Here, we present an unusual case of acute gangrenous appendicitis following a screening colonoscopy. Methods and Procedures: A laparoscopic appendectomy was performed for acute appendicitis in a 73-year old male following an unremarkable screening colonoscopy. The resected specimen was sent to pathology. Results: Screening colonoscopy revealed only sigmoid diverticulosis, with a normal-appearing appendiceal orifice. Shortly after the procedure, the patient developed gradually worsening right lower quadrant abdominal pain and chills. He presented to the emergency department the following day, where a CT scan showed evidence of acute appendicitis without perforation. Intraoperatively, the appendix was noted to be severely inflamed with a gangrenous base. The appendix was resected laparoscopically with a small cuff of cecum. Pathology showed acute suppurative appendicitis with transmural inflammation. The patient recovered without complications. Conclusion: Colonoscopy is generally considered to be a safe procedure. Postcolonoscopy appendicitis is a very rare complication. Although the exact pathophysiology remains unclear, proposed mechanisms include barotrauma, direct trauma of the appendiceal orifice, and introduction of fecaliths. As demonstrated by this case, it is important to maintain a broad differential diagnosis in patients presenting with unresolving abdominal pain following a colonoscopy.

★ Honorable Mention: Carl J. Levinson Award for Best Video Objective: Demonstrate techniques of a robotic-assisted laparoscopic resection for disseminated peritoneal leiomyomatosis (DPL). Methods and Procedures: A 42 year-old with right lower quadrant pain for 2 months. She had a prior dermoid ovarian cystectomy 6 months prior and a robotic-assisted total laparoscopic hysterectomy with uncontained power morcellation 11.5 years ago. Pelvic MRI demonstrated an 11.5 × 5.4 × 7.0 cm pelvic mass suggestive of a postoperative hematoma. She was consented for a robotic-assisted resection of a pelvic mass. Results: Patient underwent a robotic resection of a soft tissue pelvic mass. There were superficial serosal injury to the small bowel requiring oversewing. Intraoperative frozen section revealed a benign bland spindle cell tumor. Final pathology was consistent with disseminated peritoneal leiomyomatosis. The patient was discharged home on postoperative day zero and had no postoperative complications. Conclusion: Disseminated peritoneal leiomyomatosis is a rare benign gynecologic condition that can result from uncontained power morcellation. Its diagnosis and management are challenging due to its rarity and the unpredictable timing of its occurrence after morcellation. This case is particularly unique, as the patient developed DPL six months following an ovarian cystectomy. Neovascularization to the surrounding peritoneum and organs presents significant surgical challenges. Our case demonstrates essential surgical principles for performing a safe and effective resection.