Abstracts of Presentations Made at MISWeek 2023

Objective: The objective of this case report is to present the clinical findings, diagnostic approach and minimally invasive surgical treatment of a female patient with a cyst of the canal of Nuck. Methods and Procedures: The case at hand involved a 31 year old female with a 2 year history of a right inguinal mass that was associated with intermittent pain and increased with Valsalva maneuver. An ultrasound was performed, revealing a cystic mass in the right inguinal region that extended to the ipsilateral labium majus, believe to be a cyst of the canal of Nuck.The recommended treatment, facing a cyst of the canal of Nuck, is excision of the hydrocele and hernioplasty of the associated hernia if present. This is traditionally done through the inguinal canal by an anterior approach. Results: In the present case, the laparoscopic TAPP approach was preferred. Using the transabdominal preperitoneal technique, our surgical team was able to successfully remove the complete Cyst of the canal of Nuck and repair the associated inguinal hernia, without the necessity to convert to an open anterior surgery. Conclusion: It’s important to raise all health care professionals’ awareness of the rare condition known as the Nuck cyst, broadening the understanding of this entity in an effort to develop better diagnostic and treatment guidelines that adhere more and more to minimally invasive therapies that have gone unnoticed due to the disease’s rarity and medical unfamiliarity.

Objective: Patients with Chronic Pelvic Pain (CPP) remain a big challenge for physicians to manage and improve quality of life. We present a new algorithm of evaluation and treatment focused on the bladder, pudendal nerve and myofascial pain. Methods and Procedures: This is a prospective observational cohort study of 296 women aged 15 – 90yo with the diagnosis of CPP, that followed the treatment algorithm at The Center for Endometriosis, Pelvic Pain & Urogynecology in Lima, Ohio from 2016 – 2018. The evaluation started with an anesthetic challenge test (ACT) of the bladder followed by a protocol of bladder rinses and/or pelvic/pudendal blocks. Results: On the group that screened positive for ACT and followed bladder rinses: 84% of patients had a visual analog score (VAS) improvement of at least 50% (64% had VAS improvement of 80% and 41% improved 100%). Those that followed bladder rinses and pelvic blocks: 90% had VAS improvement of at least 50% (60% had an improvement of 80% and 26% improved 100%). On the negative ACT group with only pelvic blocks: 80% of patients had at least 50% improvement of VAS. All groups showed a statistically significant improvement of pain (p<0.05%). Conclusion: Management of women with CPP is complex. It usually starts with a surgical laparoscopic procedure as the first step. With the significant improvement on VAS scores in our study we believe that not only we can avoid multiple major surgical interventions due to pelvic pain, but also successfully minimize uncontrollable post op pain and improve post op surgical pain management.

Introduction: Diverting loop ileostomy is a common procedure used in management of various colorectal pathologies. Despite being reported in journals, laparoscopy assisted ileostomy closure is not described in any surgical textbook and thus not widely used. We hope to raise further awareness of this technique by sharing our experience. Methods: Retrospective review was performed involving sequential patients undergoing the procedure from March 2020 to March 2023. Procedures: One surgeon introduces a 5mm direct-view port at palmer’s point and one or two other 5mm ports to maximize their usefulness. Laparoscopic exploration and adhesiolysis is performed ensuring full bowel mobility to allow for effortless creation of anastomosis and optimal exposure of abdominal wall to allow for optimal fascial closure. Using open approach, other surgeon dissects bowel under combination of direct and laparoscopic view starting at mucocutaneous junction. Standard, double stapled, side-to-side, functional end-to-end extracorporeal anastomosis is then created. Fascia is closed without any concern for injuring bowel adhesed nearby. Finally, fascial closure is assessed laparoscopically. Results: N=40. Average operative time was 88min. Average length of stay was 2.8d. There were no intraoperative complications. Postoperatively, one patient developed aspiration pneumonia requiring ICU admission. Three patients, including the previous one, had ileus treated conservatively. Two patients developed localized surgical site infection treated with brief course of antibiotics. Conclusion: Laparoscopic ileostomy reversal is safe and effective with low perioperative morbidity. The advantages of using laparoscopy include being able to perform well visualized lysis of adhesions and being able perform, as well as verify, fascial closure.

Introduction: Siewert III adenocarcinomas represent close to 40% of EGJ cancers. They have the worst prognosis among upper GI cancers1, whose incidence has been increasing.2 While the Siewert classification system has assisted in clarifying that diverse strategies are required to address the different types of adenocarcinomas of the esophagogastric junction (AEG), there is still a lack of consensus for a homogenous treatment approach.3 The approach to Siewert III AEG typically includes a transhiatal esophagectomy with a total gastrectomy and D2 lymphadenectomy, which can be incredibly challenging when attempted laparoscopically and are often done as open procedures due to the level of difficulty. Methods and Procedures: We present the case of a 72 year-old male, diagnosed with a Siewert III AGE. He underwent a laparoscopic total transhiatal gastrectomy with a distal esophagectomy with D2 lymphadenectomy, using a transoral circular stapler for terminolateral esophagojejunal anastomosis. Initial postoperative imaging suggested an anastomotic leak, but further examination revealed a proper functioning anastomosis. Conclusions: A big challenge associated with esophagectomies are anastomotic leaks, which can often be a product of poor visibility. Studies suggest that MIS offers better patient outcomes, including reduced morbidity and mortality, compared to open procedures. This case report highlights MIS coupled with transoral circular stapler anastomotic technique as a viable approach to the surgical treatment of AEG type III. There is a growing necessity for proficient MIS surgeons who possess knowledge of expected postoperative imaging findings. Further investigation, including well designed randomized controlled trials, are still needed to tailor our surgical approach to type III AEG.

Objective: Laparoscopic sacrocolpopexy (LSCP) is a generally safe procedure with rare but potentially serious complications. The 5-item frailty index (5-iFI) has strong predictive value for adverse postoperative outcomes in urologic and gynecologic procedures. This study evaluated the 5-iFI as a predictor of complications following LSCP. Methods and Procedures: The ACS-NSQIP database was queried for patients undergoing LSCP from 2016 to 2019. Patients were stratified by 5-iFI scores of 0, 1, or ≥ 2. Differences in the rates of Clavien-Dindo (CD) complications, prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmissions were analyzed between groups and multivariate regression assessed the predictive value of 5-iFI for operative outcomes. Results: 3,907 patients were included. Higher 5-iFI scores were associated with higher rates of CDIV complications (p = 0.017) and PLOS (p = 0.021), however, on multivariate analysis, 5-iFI was not predictive of CDIV or PLOS. Alternatively, bleeding disorders were predictive of CD I/II (OR=1.215, p = 0.017) and CD IV (OR = 2.324, p < 0.001) while higher ASA scores were predictive of CD III (OR = 3.854, p=0.009) and PLOS (OR = 1.444, p = 0.031). Conclusions: LSCP is a generally safe procedure even in frail patients as evident by low rates of adverse outcomes even in patients with 5-iFI of ≥ 2. While valuable for other procedures, 5-iFI may not be an effective predictor of adverse outcomes for LSCP. Other risk factors such as bleeding disorder or high ASA score may be superior predictors of outcomes following LSCP.

Objective: While substantial literature exists regarding the cost of robotic transhiatal esophagectomy (THE), there is limited data analyzing hospital reimbursement based on insurance provider type. The goal of this study is to compare hospital reimbursement after a robotic THE for patients with Medicare versus private insurance. Methods and Procedures: With IRB approval, we prospectively followed 85 patients from 2012-2022 who underwent a robotic THE. Private insurance was defined as a coverage plan not associated with Medicare or Medicaid. Data are presented as median(mean±SD) with p<0.05 considered significant. Results: Of the 85 patients who underwent a robotic THE, 64 patients had Medicare and 21 patients had private insurance. Patients with Medicare were older (71 vs, 61 years, p<0.001) and more likely to have had a previous abdominal/thoracic operation (41% vs 10%, pIII), hospital length of stay, in-hospital mortality, or 30-day readmission. There were no significant differences in total cost, variable cost, fixed direct cost, fixed indirect cost, or hospital net margin between patients with Medicare versus private insurance. Conclusions: Despite patients with Medicare being older and with a more prominent operative history, operative and postoperative outcomes and hospital costs and reimbursement after robotic THE were found not to be different for patients with Medicare vs. private insurance. This indicates that the robotic platform may help mitigate the anticipated differences in hospitalization cost and hospital profit/loss based on insurance type.

Objective: In the era of Minimal invasive surgery, laparoscopic surgeries are the standard of care for many surgical conditions. However, a primitive problem since its inception has been Telescope lens fogging. Fogging can be attributed to vapor condensation on the lens due to the accumulation of blood, particulates, and smoke. Various preventive strategies are in practice, but there is a lack of consensus regarding a standard method to overcome this problem. Gas inflow along the scope results in a decrease in temperature leading to lens condensation; shifting the gas insufflation to an alternative port is a helpful method of prevention of lens fogging, proposed but not tested in vivo. Our study aims to observe the impact of lens fogging on alternative port insufflation. Materials and Methods: Sixty-seven patients over 18 years undergoing elective laparoscopic cholecystectomy were included in this observational comparative study, with 34 in the umbilical and 33 in lateral port CO2 insufflation during laparoscopic cholecystectomy. Lens fogging incidence among the two insufflation ports was the primary objective, and operative time and surgeons discomfort were the secondary objectives Results: Lens fogging incidence was significantly decreased (P < 0.045), and cumulative time spent in laparoscopic lens cleaning was also significantly less in the lateral insufflation group (P < 0.001). In addition, significant differences between the groups were observed (P < 0.001) in terms of surgeon Comfort (Grade 0 and 1) and discomfort level (Grade 2 and 3). Conclusion: Lateral port insufflation was superior concerning lens fogging events, reduced lens cleaning time, and increased surgeon comfort.

Background and Objectives: Acute appendicitis is one of the most common surgical emergencies in the United States. Appendiceal neoplasms are usually an incidental finding, representing about 1% of all cases of acute appendicitis. Mucinous neoplasms are rare, found only in 0.2-0.3% of appendectomy specimens. We report a case of a low-grade appendiceal mucinous neoplasm (LAMN) found incidentally in an appendectomy specimen, for which appendectomy was curative. Study Design and Methods: Laparoscopic appendectomy was performed for acute appendicitis in a 35-year-old male. The specimen was sent to pathology. Results: Preoperative CT scan revealed a dilated appendiceal tip with minimal adjacent fat hyperemia (Figure 1). Intraoperatively, the appendix was acutely inflamed. Its tip was indurated and enlarged, suspicious for an underlying neoplasm (Figure 2). The appendix was manipulated using its mesentery only, with care taken to avoid injury to its wall and potential leakage of mucin. Its integrity was preserved, and it was extracted using a sealed specimen retrieval bag (Figure 3). Histopathology revealed a low-grade mucinous appendiceal neoplasm (Figure 4). This was a well-differentiated 2.7cm tumor located in the tip of the appendix with negative resection margins. Subsequent metastatic workup and colonoscopy were negative. Conclusion: Maintaining the integrity of the appendix is crucial to prevent peritoneal spread of mucinous neoplasms. As this case illustrates, appendectomy alone can be curative for low grade mucinous neoplasms if care is taken to avoid spillage of contents during appendectomy. Our patient did not require further treatment, and appendectomy alone was curative.

Objective: We aimed to describe the incidence and identify risk factors for the occurrence of short-term major postoperative complications among patients undergoing colectomy or rectal resection for endometriosis. Methods and Procedures: A cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012-2020. We included patients with a primary diagnosis of endometriosis who underwent colon or rectal resections for endometriosis. Results: Of 755 women who underwent colorectal resection, 495 (65.6%) had laparoscopic surgery and 260 (34.4%) had open surgery. The major complication rate was 13.5% (n=102). Women who underwent open surgery had a higher proportion of major complications (n=53, 20.4% vs. n=49, 9.9%, p<0.001). In a multivariable regression analysis, hypertension [aOR 95%CI 1.84 (1.06-3.19), p=0.031], laparotomy [aOR 95%CI 1.66 (1.06-3.19), p=0.029], concomitant intestinal or rectal procedures [aOR 95%CI 2.04 (1.24-3.34), p=0.005], hysterectomy [aOR 95%CI 2.51 (1.58-3.98), p<0.001] and White race [aOR 95%CI 0.52 (0.30-0.87), p=0.013] were independently associated with major postoperative complications. In a subanalysis of laparoscopies only, chronic hypertension, other rectal or intestinal procedure and hysterectomy were independently associated with major complications, while White race was associated with a lower risk for major complications. In a subanalysis of laparotomies only, Black race and hysterectomy were independently positively associated with the occurrence of major complications. Conclusion: This study provides a current population-based estimate of short-term complications after surgery for colorectal endometriosis in the United States. Effort should be invested in increasing the use of minimally invasive surgery for colorectal endometriosis and decrease racial disparity. ★ Best Gynecology Scientific Paper

Objective: Present three different surgical cases with adnexal pathology, while considering the pros and cons for fertility sparing surgery, and demonstrating tips and tricks for optimizing post-surgical fertility. Methods: We present three different cases of adnexal pathology and their surgical intervention. The first case includes a nulliparous female with advanced endometriosis and an endometrioma. Complete excision of the endometrioma is demonstrated, as excision is associated with higher pregnancy rates and lower recurrence rates than fenestration. Our second case demonstrates tuboplasty in a patient with tubal pathology consistent with serosal adhesions. Blunt and sharp dissection are utilized to separate the tube from the ovarian fossa. After dissection, chromopertubation is used to confirm patency of the tube. The last case demonstrates management of adnexal torsion. The ovary is detorsed using blunt instruments and the ovary is preserved, regardless of suspicion for necrosis. The cyst is identified and cystectomy is performed in order to remove the nidus of torsion. In all three cases, we demonstrate a judicious use of energy around the ovary to limit damage to the viable ovarian cortex and maximize post-surgical ovarian reserve. Conclusion: Fertility sparing adnexal surgery is feasible and effective. Judicious utilization of energy is recommended. Basic skills to maintain ovarian reserve are considered essential for any gynecologic surgeon, and can maximize post-surgical fertility in all patients.

Study Objective: Cecal endometriosis, encompassing less than 5% of gastrointestinal deep infiltrating endometriosis (DIE), is an uncommon form of DIE that can be managed surgically by different approaches depending on extent of disease. The objective of this video is to review indications for both “radical” and “conservative” approaches using case specific examples. Methods and Procedures: We present a case series of two surgical approaches for patients undergoing laparoscopic management of cecal DIE. The first case is a 29-year-old female with history of DIE involving the rectosigmoid underwent or “radical” ileocecetomy, in addition to lysis of adhesions, left salpingo-oophorectomy, ureterolysis and low anterior resection with low colorectal (pelvic) anastomosis. The second case is a 37-year-old with known history of DIE located in the anterior lower uterine segment, cecum and distal ileum. In this case, partial or “conservative” cecetomy, in addition to total laparoscopic hysterectomy, right oophorectomy, and lysis of adhesions, was performed. Results: Surgeons elected the "radical" approach, or ileocecetomy, because the patient’s endometriotic disease involved the terminal ileum, cecum, appendix, and the ileocecal (IC) valve. Surgeons elected the "conservative" approach, or partial cecetomy, due to endometriotic lesions being confined to the cecum, allowing for IC valve preservation. Conclusion: The surgical approach for DIE management is based on extent of disease and its proximity to the IC valve. Conservative surgical management with IC valve preservation is preferred when feasible because of its role in slowing transit of GI contents from the small intestine into the colon but may not be possible for some patients.

Background and Objectives: Choledocholithiasis can be challenging to manage in a rural hospital without access to endoscopic retrograde cholangiopancreatography capabilities. The prevalence of choledocholithiasis is reported in 5-12% of cholecystectomies. Here, we report a case of a challenging common bile duct stone that required intraoperative laser lithotripsy for clearance. Study Design and Methods: We performed a laparoscopic cholecystectomy with intraoperative cholangiogram for acute cholecystitis. An obstructing common bile duct stone was found, requiring transcystic common bile duct exploration and laser lithotripsy. Results: Preoperative imaging showed an inflamed gallbladder (Figure 1). Bloodwork was without findings concerning for biliary obstruction (Table 1). Intraoperatively, the gallbladder appeared inflamed with severe fibrosis (Figure 2). Intraoperative cholangiogram revealed a meniscus sign at the distal common bile duct (Figure 3). Intravenous glucagon administration with flushing of the common bile duct and attempted clearance with a 3-French embolectomy catheter were unsuccessful. Subsequent removal attempts with a retrieval basket under fluoroscopic guidance were unsuccessful and resulted in the basket becoming lodged to the stone and irretrievable. Transcystic common bile duct exploration with choledochoscopy was performed (Figure 4), and a 272 Micron Holmium laser was used to fragment the stone. Following this, the basket was successfully retrieved and all stone fragments were evacuated. Completion cholangiogram revealed a normal and patent biliary anatomy (Figure 5). Conclusion: While endoscopic retrieval is the standard of care for choledocholithiasis, our case illustrates laser lithotripsy as an effective alternative. This is especially relevant in resource-limited rural environments where choledocholithiasis is incidentally encountered intraoperatively.

Objectives: Evaluate the use of the robotic arm for optics for reduction of tremor, hands-free operation, single-operator capability, reduction of surgeon positional stress, reduction of post-operative pain, and optimization of operating room staff. Methods and Procedures: From June to November 2022, 45 patients underwent surgery for endothoracic neoplasms: 5 esophagus, 6 thymus and 34 lungs. Three cases for open conversion were excluded. In the Group A (standard) there were 3 esophageal, 3 thymic and 16 lung cancers, in the Group B (robotized arm) 2 esophageal, 3 thymic, 18 lung cancers. In each case, 10mm 2D/3D 30° optics were used. Ages were recorded as gender, comorbidity, time of operation, post-operative stay and pain. No patient was lost at follow-up. Results: Operative time was significantly reduced in Group B compared to standard Group (139.71±17.81 minutes vs. 156.75±29.64 minutes – p=0.0354. We report a significative reduction of post-operative pain in Group B (5 vs. 12 – p=0.0258). Conclusions: The use of the optic robotized arm provides a stable image without tremors as in robotic surgery. Furthermore, it is possible to maintain complete and precise control over the operating field with only the use of the head, reducing the cleaning of the optics by up to 20%. The robotic arm allows for immediate conversion to open if necessary. It is also possible to perform the procedure in complete autonomy, reducing the reaction times of the collaborator and making navigation within the chest more natural, less traumatic, and faster. Finally, the operating room staff is optimized with savings on management costs.

Rogerio Liane S.R, 13 Rosemurgy Alexander S, 1, 2, 5, 6, 7, 9, 19 Rosen Roni Y, 8 Rosenstock Adam, 8 Ross Sharona B, 1, 2, 5, 6, 7, 9, 19 S Sacco Jana, 10 Sadiq Aziz, 22 Sakhireddy Vineet, 26 Salom Emery M, 17, 20 Sardzinski Emily, 2 Sarkar Papri, 14 Satava Richard, 18 Saverio Salomone Di, 24 Semova Teodora, 12 Semova Teodora Krasimirova, 17 Shapera Emanuel A, 1, 3 Shibata Renae, 13 Shivji Azra, 16 Shu Diego, 11 Siedhoff Matthew T, 11, 15 Silva Marycarmen Mendoza, 25 Slavin Moran, 5, 19 Soman Urmila, 13 Staudinger Kelsey, 3 Sucandy Iswanto, 1-2, 5-7, 9, 19 Sundaram Mahalakshmi Thayumana, 13 Syblis Cameron, 5, 9, 19 Syed Radha, 12, 17 T Tessier Deron, 25 Tew Jenna R, 17 Thappa Sarah, 10 Todd Sarah, 16 Toloza Eric M, 17 Tomov Slavcho Tomov, 12, 17 Toomey Paul, 2 Touadi Melissa, 3 Trad Karim S, 7 Tran Nguyen, 26 Trimmer-Torres Marina, 21, 24 Trimmer Marina, 24-25 Trooboff Spencer, 2 Trotto Michael, 1, 9 Truong Mireille D, 11, 15 V Van Horn Carter Benjamin, 25 Vasicka Ian M, 11 Vest Adriana N, 14 Vikis Elena, 24 Vladova Paulina, 25 Vyas Pooja, 15 W Wady Heitham, 19 Wall Rachel A, 6 Wang Daniel, 20 Wang Pengfei, 15 Williams Annalese, 13 Wright Kelly N, 11, 15 Y Yotsov Tsanko I, 23, 25 Younos Ahmed, 2

Objective: Evaluation of radical prostatectomy in male dogs as a training model for robotic radical prostatectomy in humans. Methods and Procedures: Two D and 3D laparoscopies, performed by a veterinary surgeon with extended experience in laparoscopy, were used to evaluate the anatomy of the prostate, the ductus deferents, the urethra, and the neuromuscular pedicles in male canine cadavers. The robotic radical prostatectomies were conducted by a human surgeon with extended experience in robotic radical prostatectomy following the protocol described by the European Robotic Urology Surgery. The anatomical similarity, technical reproduction, and dissection realism were graded during the robotic procedures with a scale from 1 to 5. Results: Four radical prostatectomies were performed with 2D laparoscopy and four with 3D laparoscopy. Male dogs do not have seminal vesicles and dorsal venous plexus, but every other structure was present. The neurovascular bundles were easily visualized on each side of the prostate and the urethra. Five radical prostatectomies were performed with robotic surgery. The visualization of the anatomical structures was graded from 2.2 to 5, and the technical reproduction from 3.4 to 5 during robotic radical prostatectomy. The dissection realism was graded from 2.4 to 5. The vesicourethral anastomosis was graded 5 for visualization, dissection realism, and technical reproduction during robotic radical prostatectomy. The anastomosis were all performed with unidirectional barbed sutures. Conclusion: Male dogs could be used as a training model to learn radical prostatectomy with robotic surgery. The vesicourethral anastomosis is very similar to the step in human patients. ★ Best Urology Scientific Paper Click here to view the Disclosure Index

Objective: To illustrate the canopy concept of bladder dissection in the face of difficult bladder adhesions in previous caesarean sections. To tackle this, we propose a different approach, in which the dissection of bladder is done after ligating the uterine artery first. Method/Procedure: The video demonstrates TLH in a patient with previous 3 caesarean sections with partial obliteration of anterior cul de sac. Firstly, broad ligament is opened widely posteriorly and uterine artery sectioned close to the uterosacral ligaments. The uterovesical space is entered easily at the level of manipulator cup, where the bladder is loosely adherent. With the canopy concept when we proceed with bladder dissection it looks as if the bladder is stretched over like a canopy and we work in the cotton candy UV space below and are able to reach till the contralateral uterine artery. Once the uterovesical space is opened completely only then the uterovesical fold of the peritoneum is sectioned and TLH is completed. Result: Out of 450 cases done by this new approach over six years there was no bladder or ureteric injury. Ease of bladder dissection in avascular plane was paramount. Conclusion: We present a different approach to bladder dissection in TLH where the bladder remains adherent on top and we work underneath in the UV space over the manipulator cup. This approach aims at easy bladder dissection in an avascular plane and avoidance of bladder injury, an endeavor to make TLH safe.

Objective: To investigate racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States. Methods and Procedures: A retrospective cohort study. We used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012-2020. Patients were identified through ICD-9/10 codes 617.0/N80.0 (endometriosis of uterus). We compared 30-day post-operative complications across the different racial and ethnic groups. Complications were classified into minor and major complications according to the Clavien-Dindo system. Results: A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander and 91 (0.7%) American Indian of Alaska Native. Post-operative complications occurred in 8.8% of cases (n=1,104), including major complications in 3.1% (n=385). After adjusting for confounders, Black race was independently associated with increased risk of major complications [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.54 (1.16-2.04), p=0.003]. Laparotomy was performed in 13.7% (n=1,725) of cases. Compared with White race, the aOR for undergoing laparoscopy was 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for Black or African American, 0.33 (95%CI 0.27-0.40) for Asian and 0.26 (95%CI 0.17-0.41) for Native Hawaiian or Pacific Islander race. Conclusion: Among women undergoing hysterectomy for adenomyosis, Black or African American race was associated with an increased risk of major post-operative complications. Compared with White race, Hispanic, Black or African American, Asian and Native Hawaiian or Pacific Islander races were less likely to undergo minimally invasive surgery.

Objectives: Manual surgical staplers play a dominant role in minimally invasive lung surgery, but powered staplers represent a new option. We analized the advantages of the new powered staplers in terms of ergonomics, malfunctions and tightness of the suture on lung tissue. Methods and Procedures: From January to November 2022 60 major lung resections were included, because 5 ones were excluded for open conversion. Standard staplers were used in 32 cases (Group A), powered surgical staplers in the remaining 28 cases (Group B). We analyzed operative time, post-operative length of stay, post-operative complications, serum/blood loss, air leaks, comparing the data between the two groups. The surgeon’s degree of satisfaction in terms of ergonomics was also analyzed. Results: No significative differences were in age, sex, comorbidity, neither in air leaks, post-operative atelectasis and length of stay. Operative time was significative reduced in Group B (65.5±7.2 minutes vs. 69.7±5.2 minutes – p = 0.0193) as the serum/blood loss (81.1±9.6 ml vs. 95.2±8.9 mL – p = 0.0032). Conclusions: Our experience showed that the use of powered staplers makes it easier for the surgeon to perform the procedure without affecting its quality. Furthermore, the average firing force reduced by at least 95% than manual staplers to reduce operator fatigue and minimal distal movement to enhance staple line integrity. Another advantage is the reusable or/and single use optional. The learning curve for using these devices is rapid and the ability to control opening and firing with one hand translates into economy of movement for surgeon.

Objective: To demonstrate the feasibility of doing a simple diagnostic procedure of Hysteroscopy with Endometrial sampling in a daily office setting during regular office hours. Methods and Procedures: Retrospective collection of data from office procedures during last 5 years at 2 locations using a simple disposable hand held Hysteroscope-feasibility, time investment, required instrumentation, required personnel, the actual procedure, documentation of findings in EMR and follow up of pathological diagnosis and further management guidelines will be discussed. Complication rate will be discussed. Results: The results of the retrospective analysis will show that it is completely feasible to perform office hysteroscopy with minimal personnel, minimal time and financial investment .The complication rate is low and mostly minor. The success rate of performing the procedure exceeded 95%.The diagnostic capability of office hysteroscope matched that of a larger scope with fluid management system in a hospital ambulatory setting. Histopathological correlation between Endometrial Biopsy and Endometrial curettage differed significantly in a few cases and the reasons for that will be discussed. Conclusion: Office Hysteroscopy is a very important diagnostic tool which must be incorporated in every GYN office. A blind Endometrial biopsy leaves out many significant diagnostic possibilities which may impact the health of the patient population in an adverse way. This procedure reduces the number of people going into the OR unnecessarily.

Objective: eTEP bilateral TAR for ventral hernia repair is a safe and effective option for ventral hernia repair using a single dock. Methods: Video presentation of a 45-year-old female with a history of IPOM umbilical hernia repair, who underwent a single dock bilateral TAR for recurrence. Results: Appropriate patient selection and positioning are crucial. Port placement medial to linea semilunaris. TAR is performed when the posterior rectus sheath is difficult to close without tension. Multiple benefits of this procedure include less pain, less recurrence, less risk of adhesions, and much cheaper (no composite mesh needed). Conclusion: This technique is a great alternative with excellent results if performed in appropriate candidates.

Objective: Bile duct injury is a rare complication in the era of laparoscopic surgery, however it can lead to serious consequences. Repair of bile duct injury with Roux-en-Y hepaticojejunostomy is a technically demanding operation especially when undertaken laparoscopically. Robotic technology improves surgeon’s dexterity for fine suturing task such as in creating a delicate hepaticojejunostomy. Technical description of robotic RY hepaticojejunostomy is very limited. In this video, we describe our robotic technique for delayed repair of an E2 bile duct injury. Methods and Procedures: A 53-year-old man presented in our office with a bile duct injury after an urgent laparoscopic cholecystectomy. One week later, the patient was readmitted for fever and jaundice. Endoscopic Retrograde CholangioPancreatography (ERCP) revealed an abrupt cutoff of the mid common bile duct. The operation began with a diagnostic laparoscopy and adhesiolysis to find the proximal common hepatic duct. Once the anatomy was confirmed, a single RY Hepaticojejunostomy was created using a running suture technique, starting from the posterior wall of the anastomosis. A close suction surgical drain was placed in the infrahepatic fossa at the end of the operation. Results: Operative duration was 3 hours with 75cc of blood loss. Postoperative recovery was uneventful and patient was discharged on post-operative day #4. The surgical drain was removed before discharge. No complications were seen at a 1-month follow-up. Conclusion: Robotic approach for delayed repair of E2 bile duct injury is safe, feasible and reproducible with excellent clinical outcomes. This technique can provide an alternative minimally invasive method to the existing traditional open operation. ★ Best General Surgery Video

Objective: We present the case of a 36 year old woman who presented as an outpatient referral with a primary complaint of severe gastric reflux who had a comorbidity of obesity with a BMI of 41. The video presented is an example of a technically complex procedure utilizing best practices in minimally invasive technique for the management of morbid obesity in the setting of gastric reflux. Methods and Procedures: When selecting a bariatric procedure for the management of morbid obesity, a Roux-en-Y gastric bypass (RYGB) is the procedure of choice in morbidly obese patients suffering from medically refractory gastroesophageal reflux disease (GERD). In the context of cholelithiasis, a cholecystectomy can also be performed. The patient underwent a synchronous laparoscopic RYGB, hiatal hernia repair (HHR), and cholecystectomy. Results: The patient had an uncomplicated postoperative course and was discharged on postoperative day 1. At her 3-month follow up she had lost a total of 42 pounds, has no remaining GERD symptoms, and is without nutritional deficiencies. Conclusion: A laparoscopic RYGB is the procedure of choice in patients with morbid obesity and medically refractory GERD. Minimally invasive surgery allows for multiple abdominal procedures to be performed synchronously with rapid recovery and minimal complications. This video presentation demonstrates the technique required to perform a laparoscopic RYGB, cholecystectomy, and HHR in a patient who had an excellent surgical outcome.

Objective: This video depicts a robotic pancreaticoduodenectomy undertaken in a 76-year-old woman who presented with jaundice and RUQ pain. Methods and Procedures: The patient was referred for an EGD which revealed abnormal villous tissue surrounding the major papilla. EUS/FNA returned as positive for adenocarcinoma. Results: The operation began with diagnostic laparoscopy which showed no evidence of carcinomatosis or liver lesions. Lysis of adhesions occurred in the right upper quadrant, the patient had a history of cholecystectomy. The duodenum was carefully mobilized. The jejunum was brought up into the right upper quadrant and the gastrohepatic ligament was opened in a stellate fashion. The duodenum was divided allowing the stomach to be retracted to the LUQ. Dissection along the duodenum, uncinate process, and neck of the pancreas allowed for the transection of the pancreas. Peripancreatic lymph nodes were excised and collected. Reconstruction began with the hepaticojejunostomy anastomosis with two absorbable barbed sutures. Next, the two-layer pancreaticojejunostomy anastomosis was undertaken with non-absorbable barbed sutures for the outer layer and absorbable barbed sutures for the inner layer. Lastly, the transverse colon was elevated to allow for the duodenojejunostomy anastomosis. A fibrin-sealant was injected over all three anastomoses and a 10-French flat JP drain was brought to the axillary line and sutured to the skin. Conclusion: Final pathology confirmed adenocarcinoma associated with an ampullary tubulovillous adenoma. The patient had an uneventful postoperative course. This video demonstrates how a difficult HPB procedure may be successfully completed while still maximizing the advantages of the robotic platform.

Objective: We are introducing a new surgical technique to close the 10 mm or larger laparoscopic port site with safe, reusable, and cost-effective method using Graham’s Nerve Hook and two S-retractors. Methods and Procedures: This new technique used two S-retractors, a Graham’s nerve hook and two needle holders to close the larger port site’s fascia and peritoneum under a direct visualization. We followed 20 patients who underwent the new Port Site Closure technique using Graham’s nerve hook versus Carter-Thomason Port Closure technique. These patients were followed for two years to compare the outcome. The length of time it took for closure, outcome, cost per case were looked at. Results: While both techniques yielded similar average time, incision size, and absence of hernia development post-operation, the new Lee’s Port Site Closure technique using Graham’s nerve hook was more cost-effective approach as it was ⅙ the cost of Carter-Thomason Port Closure technique, and the new technique took one minute less than Carter-Thomason Closure technique Conclusion: Both port site closure techniques yielded similar results. However, between the two techniques, Lee’s Port Site Closure technique was more cost effective and was a slightly faster method. Due to the small sample size of the study, we must expand our study to include a much bigger patient population for a more accurate comparison.

Background: Dermoid cyst is one of the most common ovarian lesions in premenopausal women; ovarian preservation should be attempted when laparoscopic cystectomy is offered to maintain fertility and hormonal homeostasis. Hilum preservation should be accomplished to avoid ischemic injury of ovarian tissue. Case: A 17-year-old G0 presented to the emergency room complaining of chronic pelvic pain of progressive severity with new onset of associated lower back pain, nausea, and vomiting. Abdominal and pelvic examinations were performed and were positive for mild to moderate hypogastric tenderness. Transvaginal ultrasound was performed resulting in an 8 cm heterogenous, hyperechoic mass in the right ovary with patent blood flow in both ovaries; findings were consistent with a dermoid cyst, which was confirmed after an abdominopelvic CT scan. Management options were discussed, and the patient expressed the desire for ovarian preservation, after reviewing the risk and benefits she consented to Laparoscopic right ovarian cystectomy with possible oophorectomy, and she was taken to the OR and right ovarian cystectomy was performed without complications. Conclusion: Oophorectomy in premenopausal women should be left as last resort, and cystectomy should be attempted even when ovarian hilum disruption is encountered secondary to dermoid cyst contents or wall; this would offer the patient better outcomes in fertility and hormonal homeostasis preservation. Hilar preservation techniques should be explored and developed.

Introduction: Gastrointestinal (GI)endoscopy is an important and critical method for diagnosis and treatment of gastrointestinal disease and the prevention & palliation of Gastro intestinal cancers. The use of GI endoscopy and colonoscopy has resulted in improved clinical outcomes but there is limited information on the patterns of diseases diagnosed using this method in Uganda. Our aims were to describe the trends of diseases identified by use of GI endoscopy and colonoscopy, the age and gender distribution among patients who are referred for these procedures at Case Hospital. Methods: Retrospective review of results of available endoscopy and colonoscopy procedures performed by the surgeon/gastroenterologist over 8 years at case Hospital. Institutional consent was sought. Results: 142 results were reviewed and analyzed. Out of these analyzed, 54% (77) were males and the rest were females. Nearly all the reviewed files had abnormalities. Most patients had more than one pathology and the most common diagnosis during endoscopy was these three together:23% (32) had hiatal hernia, GERD and gastritis. The followed by patients who had (17) GERD & hiatal hernia. Among 19 colonoscopies diagnostic findings were seen and majority had colitis, haemorrhoids and diverticulitis. Conclusion: Gastro intestinal endoscopy and colonoscopy have a role in diagnosing patients presenting with gastro intestinal or colon disease. Thus improved management and clinical outcomes of patients.

Background and Objectives: Radiofrequency ablation is an emerging technique available for the decrease in size of leiomyomas with presumed decreased morbidity compared to myomectomy. This is a case of a patient s/p Radiofrequency ablation who was readmitted in septic shock secondary to uterine abscess with subsequent fertility sparing management. Study Design and Methods: Patient is a 41 year old G0 who underwent Laparoscopic Radiofrequency Ablation with concomitant hysteroscopic resection. She presented to the emergency department on postoperative day#12 with lower abdominal pain, diarrhea, and bloody vaginal discharge, leading to admission for septic shock and treated with broad spectrum antibiotics. She expressed a desire to maintain fertility and was counseled regarding the need for hysterectomy in case of acute decompensation. CT Imaging showed endometrial cavity filled with air and fluid with multiple areas concerning for dehiscence with appearance of a large abscess in uterus. She was stabilized, but due to persistent leukocytosis, the decision was made to take the patient for an exam under anesthesia with uterine irrigation and intrauterine drain placement. Leukocytosis resolved and patient was discharged on hospital day #12. Results: Patient was seen outpatient one and four weeks after discharge, with ultrasound imaging completed six weeks after initial surgery. She remained afebrile with progressively decreasing vaginal discharge and minimal pain. Conclusion: With this new treatment modality, further studies are required to establish safety parameters in regards to preoperative antibiotic treatment, ablation time, distance from endometrial and abdominal cavity, concomitant hysteroscopic treatment, and appropriate management of complications.

Objective: To share a new, cost effective, and innovative way for residents to train with robotics that incorporates live, non-computer generated, robotic experience. Methods and Procedures: A simulation was set up using an inflated penrose drain as a loop of small bowel, and residents at our institution were tasked with stapling across it and performing a stapled side-to-side anastomosis with a handsewn closure of the common channel. This exercise incorporates various maneuvers including stapling, suturing, knot-tying, and use of the third arm with a live robotic experience. Results: First and Second year residents were surveyed before and after the session about their comfort level and experience with computer simulations. There was a 57.6% increase in the comfort level in using the robot after the session, raising the average from 2.8 to 4.3 on a scale of 1 to 5. Conclusion: Computer simulation, while being a very good modality, is lacking in many ways when it comes to training residents for real life situations. Proficiency with the new technology comes with frequent use and practice. Our study shows that residents prefer to use actual instruments and sutures to prepare for real cases and develop confidence. This exercise encompasses many techniques in a quick and cost-effective manner and will hopefully lead to more innovative ways to get residents early experience with the robot and even allow veterans to sharpen their skills.

Objective: Gender-affirming surgery has advanced since rising to the forefront of academic medicine and benefiting from recent surgical innovations. The most common method for feminizing genital reconstruction is penile inversion vaginoplasty, which can be performed robotically using peritoneal flaps for improved vaginal depth and cosmesis. This video shows a streamlined technique for robotic-assisted penile inversion peritoneal flap vaginoplasty (PIPFV). Methods and Procedures: From October 2022 to March 2023, 26 transgender females who received robotic-assisted PIPFV were identified. A neo-vaginal space is created by dissecting along the plane between denonvilliers fascia and the rectum and sequentially dilating to 3.8 cm. A posterior peritoneal flap is developed. An anterior flap is created by mobilizing the bladder. The anterior and posterior flaps are sutured to the penile inversion graft and then sutured together to form the apex of the neovagina. Peri-operative information and outcomes were reported with a mean and standard deviation. Results: The mean patient age was 36 ± 13 years. Mean operative time for the robotic-assisted period of the surgery was 104 ± 13 minutes and mean length of stay was 3.1 ± 0.8 days. The most recent depth measurement was on average 17.3 ± 1.5 cm at a mean follow-up of 74 ± 30 days. There were no intra-operative or 30-day post-operative complications related to the robotic portion of the surgery. Conclusion: Robotic-assisted PIPFV demonstrates a favorable option for feminizing genital reconstruction. This streamlined technique simplifies the procedure while achieving desirable vaginal depth and minimal complications. ★ Best Urology Video

Objective: To Introduce a new technique to temporarily block bilateral uterine arteries in laparoscopic myomectomy, in order to decrease blood loss. Methods and Procedures: Patient was taken supine lithotomy position and a uterine manipulator was placed. A 12 mm trocar was placed in midline and 2 cm above suprapubic symphysis. Laparoscopic dissection was performed above the uterine manipulator ring, towards the ipsilateral round ligament. With the dissection in layers and millimeter to millimeter, the uterine artery was exposed. A similar procedure was performed on the other side. Laparoscopic bull dogs were used to block the uterine arteries. Laparoscopic myomectomy was then conducted following routine fashion. Finally, the suprapubic symphysis incision was extended to about 2 cm. Fibroid specimen was removed from this incision by containing morcellation. Results: The surgery was completed in 3 hours, with EBL 100cc, without intraoperative or postoperative complications. The patient was discharged on POD#1. Conclusion: Compared to uterine artery blockage at pelvic side wall, the blockage of uterine artery at cervical level is easy to perform with high success rate.

Objectives: Data regarding vaginal and perineal lacerations occurring during total laparoscopic hysterectomy (TLH) is limited and there is no published data regarding lacerations in transgender and non-binary patients undergoing TLH for gender affirming care. This pilot study examined rates of intraoperative vaginal and perineal laceration in patients who underwent gender-affirming TLH (GATLH). Materials and Methods: This was a retrospective review of all patients who underwent a GATLH with a faculty surgeon at a tertiary academic institution from 2015 through 2022. Data collection included demographic information, tobacco use, pre-operative menstrual status, hormone therapy use, presence of laceration and intervention required, uterine weight, and surgeon. Results: Of the 94 patients included, 83 identified as transmasculine (88.3%) and 11 as nonbinary (11.7%); age range was 18 to 64 years (mean 29.67, SD 7.97). The rate of vaginal and perineal lacerations was 13.8% (13/94). Patients receiving testosterone had a laceration rate of 14.0% (12/86), while patients not receiving testosterone had a rate of 12.5% (1/8). Amenorrheic patients with completely suppressed estrogen had a laceration rate of 16.4% (9/55), patients with incompletely suppressed estrogen with breakthrough bleeding had a rate of 4% (1/25), and non-suppressed menstruating patients had a rate of 21.4% (3/14). Conclusion: In this pilot study, the rate of vaginal and perineal lacerations in GATLH was 13.8%. Small sample size limited ability to identify statistically significant risk factors and protective measures in this population. Further study is needed.

Objective: Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has been recently implemented in minimally invasive surgery (MIS) to enhance intra-operative visualization of anatomic structures and facilitate surgery. The objective of this case report was to detail our preliminary experience in utilizing ICG technology in robotic general surgery. Methods and Procedures: 41-year-old male with a history of deep vein thrombosis, was found to have an enlarged lymph node involving his mesentery during his CT scan. He was referred to an oncologist who performed a PET/CT, and confirmed the presence of an FDG-avid mesenteric mass measuring 2+ cm. No other FDG-avid lesions were identified. The patient was referred to our General Surgery service for evaluation to undergo excisional biopsy of this lesion. The Interventional Radiology team injected the mass with ICG, and we subsequently used near infrared fluorescence imaging to accurately localize, and circumferentially dissect the mass out. Results: The final pathology with flow cytometry demonstrated follicular hyperplasia with one atypical focus concerning for nodular lymphocyte predominant Hodgkin lymphoma. One month after surgery, the patient had no recurrence and was symptom free. Conclusion: Our preliminary experience validated the safety and effectiveness of ICG technology in general surgery and highlighted its potential advantages as adjunctive surgical technology in patients undergoing laparoscopic or robotic abdominal procedures. The use of NIRF was also cost-effective as no added costs were required except for the ICG dye, which costs around $100 dollar per bottle. The most prevalent and valuable applications in general surgery encompassed cholecystectomy, sentinel lymph node dissection and enteral anastomosis.

Objectives: Management of laparoscopic scar pregnancy excision after bilateral uterine artery clipping and primary repair of uterine defect. Methods and Procedures: Cesarean Scar Pregnancy (CSP) is implantation of blastocyst into the myometrial defect of previous cesarean incision. It is a rare and potentially life threatening ectopic pregnancy with increasing prevalence due to increasing Cesarean section rates. All available treatment modalities are associated with high risk of massive haemorrhage and need for hysterectomy. 31-years G5P2A2, with previous 2 cesarean deliveries and 2 surgical abortions at 9 weeks gestation was referred to our tertiary care hospital with incidental ultrasound diagnosis of CSP. 4 ports placed - One 10 mm, three 5 mm ports. Bilateral uterine artery clipping - hemo-lock 5 mm laparoscopic clip applicator. Intramyometrial injection of 50 ml of diluted vasopressin (0.1 units/ml). Dissection of uterovesical fold and bladder pushed down. Unruptured ectopic gestational sac removed en masse. Rent closed in 2 layers with absorbable 180 barb sutures. Trans- vaginally introduced Hegar’s dilator as guide for identifying the margins and delineating anterior and posterior walls of uterine cavity. 4 ports placed - One 10 mm, three 5 mm ports. Bilateral uterine artery clipping - hemo-lock 5 mm laparoscopic clip applicator. Intramyometrial injection of 50 ml of diluted vasopressin (0.1 units/ml). Dissection of uterovesical fold and bladder pushed down. Unruptured ectopic gestational sac removed en masse. Rent closed in 2 layers with absorbable 180 barb sutures. Trans- vaginally introduced Hegar’s dilator as guide for identifying the margins and delineating anterior and posterior walls of uterine cavity. Results: The total operating time was 75 minutes with an estimated blood loss of around 200 ml. The patient was discharged on first POD Conclusion: Primary laparoscopic management of cesarean scar pregnancy not only offers low complication rates but also allows for repair and revision of Cesarean scar defect in the same sitting. Bilateral uterine artery clipping offers better hemostasis and decreases the need for emergent hysterectomy.

Objective: COVID-19 infection has commonly been considered a virus that causes mainly respiratory symptoms. However, the incidence of gastrointestinal manifestations is becoming more apparent. The purpose of this study was to evaluate the outcomes for patients with gastrointestinal manifestations and COVID-19. Methods and Procedures: Patients who tested positive for COVID-19 between January to November 2020 were recorded and evaluated in a medium-sized hospital. The data are presented as median (mean +/- standard deviation). Results: Six hundred and twenty-eight patients tested positive for COVID-19. Three hundred and twenty patients were men (51%). The age was 67 (64 +/- 17.8) and the BMI was 28 (30 +/- 8.64). Eighty-nine patients (14%) presented with gastrointestinal manifestations. The most common chief complaints were vomiting (5%, 33/628), abdominal pain (5%, 29/628), and diarrhea (2%, 15/628). The most common diagnoses were dehydration (3%, 21/628), vomiting (2%, 14/628), and gastrointestinal bleeding (2%, 12/628). The mortality for all patients was 21% (130/628) and mortality for patients with gastrointestinal manifestations was 17% (15/89; p = 0.09). The lowest mortality was for patients with gastroesophageal reflux disease (2%; 2/130) or diarrhea (0%, 0/130; p<0.05). There was no significant difference in mortality for patients with or without gastrointestinal manifestations when comparing age, gender, or BMI. Conclusion: Gastrointestinal manifestations of COVID-19 are not uncommon and patients diagnosed with gastroesophageal reflux disease or diarrhea during COVID-19 infection have improved chances of survival.

Objective: Enhanced Recovery After Surgery (ERAS) pathways are evidence-based practices that minimize perioperative physiologic stress, thereby reducing postoperative complications and recovery time. This study aimed to assess the Canadian application of and adherence to ERAS protocols during minimally invasive gynecologic surgery, and identify barriers to ERAS uptake. Methods and Procedures: A self-administered cross-sectional survey was distributed to Obstetrics and Gynecology residents, fellows, and attendings through three national listservs from February 2021 to January 2022. The survey assessed 14 perioperative components per the American Association of Gynecologic Laparoscopists ERAS consensus guidelines. Results: 158 responses were analyzed of which 77% were attendings. 42% work within an established ERAS protocol. While 89% engage in preoperative anemia optimization, only 43% target the recommended hemoglobin >120g/L; notably, there was no significant difference in adherence rate with or without an ERAS program. While the majority counselled on hyperglycemia and sleep apnea, a smaller proportion (16-39%) discussed obesity, smoking cessation, and alcohol reduction. There was poor adherence to preoperative carbohydrate-loading (16%); however, this was significantly higher within ERAS programs (p< 0.001). Postoperatively, there was high adherence around multimodal analgesia, diet advancement (99%), and early ambulation (89%). Most respondents felt that ERAS pathways were safe (98%), and improved patient outcomes (82%). Conclusion: While the implementation of formal ERAS pathways differs between provinces and hospital sites, practitioners engage in various components of ERAS as per the consensus guidelines. Future and targeted research around low-adherence components would be beneficial in identifying and addressing barriers to optimize surgical care.

Objective: Rectal surgery is rapidly evolving. Robotic rectal cancer surgery has been implemented to overcome some technical difficulties in pelvic rectal dissection and lower conversion rates. Although it is found that the learning curve in robotic-assisted surgery in general could be shorter than in laparoscopic procedures, the learning curve for robotic rectal cancer resections remains steep and long. Methods and Procedures: A prospective study was performed by the teams of University Hospital “Dr Georgi Stranski”- Pleven and University Hospital “St. Marina” – Varna, using a robotic surgical system. The patients were divided into two groups: the first 28 cases and the subsequent 17 patients. After the 28th case, an ICG fluorescence imaging to assess bowel perfusion was introduced in our practice. Multivariate analysis was used to assess the correlation between patient characteristics, operation duration, conversions, duration of hospitalization, complications, bleeding, reoperation, type of operation and ICG usage. Results: Forty-five patients were included: 32 men (71.1%) and 13 women (28,9%). The operative time was shorter in group II for both docking (p=0,691) and console time (166 vs 147 min, p=0,020). Cumulative sum analysis (CUSUM) was used to study the learning curve. In group I, two postoperative complications were reported (ileus and anastomotic leak) and in group II, one postoperative ileus was reported. In total, two conversions were seen, all in group I. Conclusion: The learning curve in robotic rectal resections for rectal cancer seems similar to the laparoscopic learning curve. A statistically significant reduction in console time was seen after the 28th case.

Objective: The performance of the sentinel lymph node identification in cervical cancer has been largely studied with various mapping techniques and dyes being successfully applied. The primary objective of the present study was to assess the rate of bilateral sentinel lymph node (SLN) detection with Indocyanine green (ICG) in cervical cancer patients undergoing minimally invasive robot-assisted surgery. Methods and Procedures: Seventy-nine patients with histologically proven cervical cancer FIGO IB stage were included in this 3-year prospective ongoing study between July 2020 to March 2023. Sentinel lymph node mapping was performed with ICG, followed by robot-assisted radical hysterectomy and a total pelvic lymphadenectomy. Results: The detection rate was 98.7% (78/79) and in only one case no sentinel lymph node was visualized. In 8 of 78 cases the final histology report confirmed the presence of nodal metastasis in the ICG-positive lymph nodes. Bilateral sentinel mapping was successful in 74% of the cases (59/79) and unilateral sentinel lymph nodes were identified in 19 women (24%). Most patients had stage IB1 lesion (77%), followed by IB2 (18%) and IB3 (3.70%). Conclusions: The application of ICG for identification of sentinel nodes in early-stage cervical cancer is feasible and effective method for assesment of regional lymph node basin. Additional data and randomized controlled trials are required to evaluate its oncological significance in larger tumors >2 cm.

Objective: Describe a unique colposcopic innovation; highlight salient technological nuances and suggest how this digital speculocolposcope (DSC) may enable physicians to improve their colposcopic expertise. Methods: The optical/digital HD multispectral colpomicroscope has a magnification of up to 112x, whether used in handsfree or handheld mode. Coupled with a multifunctional speculum, a wide real-time field of view of the cervix and upper vaginal vault is enjoyed. Evaluation of the vulva, lower vagina, perineum/anus may also be accomplished using the DSC in a “hand-held” manner. Unlike other digital colposcopes which require the user to back away from the examination area to prepare for sampling or treatment maneuvers and then re-position the colposcope again, the speculum-integrated DSC allows accurate auto-focus at a fixed distance. Once the DSC locks on to the target, it continuously maintains that focus image. The specially designed speculum provides adequate operating space for sampling, biopsies, & surgical interventions while preventing vaginal sidewalls from collapsing and shadowing the cervix. True-green illumination, a marker editing tool with AI-based decision-supporting tools aid in documenting areas of interest. Captured images are archived in a cloud based system along with a specific App permitting secure storing & sharing of patient information. Results: Colposcopy has not advanced much since 1925. New developments have reached a point to bring colposcopy to a new level. Furthermore, it begs the question if visual colposcopy will become a standard of care? Conclusions: This technology allows the patient to see real-time what the physician sees; increasing transparency and engaging the patient in their care.

Objective: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures being performed in the US. An essential step of this surgery is gastrojejunal anastomosis (GJA). The two most common stapling techniques used are linear GIA (LA) and circular EEA (CA). This study aims to compare the outcomes of these two techniques performed by two fellowship trained surgeons at a single institution. Methods and Procedures: Retrospective review of all LRYGB surgeries performed in 2021 and 2022 was done. Patients were divided into two groups; group LA and group CA based on the type of GJA performed. Perioperative parameters analysed and compared. Results: A total of 267 patients were reviewed; group LA (n=158) and group CA (109). Preoperative comorbidities like diabetes, hypertension, hyperlipidemia was similar in both groups. Operative time was shorter in CA group 110 minutes (102-122) compared to LA group 126 minutes (111 – 136) (p value <0.001). Average weight loss at 6 months was more in LA group - 25.9 kg compared to CA group - 21.3 kg (p value 0.003). There was no difference in weight loss at 1 year. There was no difference in postoperative complications, including wound infections, pulmonary embolism, marginal ulcers, bleeding, perforation, stricture, readmission, or reoperation. Conclusion: Operative time was shorter in CA group. LA group had better weight loss at 6 months, there was no difference in weight loss at 1 year. Both techniques have similar outcomes. The choice of technique should be based on surgeon training and experience. ★ Best General Surgery Scientific Paper

Objective: Laparoscopic Cholecystectomy is one of the most commonly performed operations. Bile duct injuries (BDI) remain a catastrophic complication of cholecystectomy associated with poor post-operative outcomes such as morbidity, mortality, and reduced life expectancy. BDIs are estimated to have an incidence of 0.15-1.5%. It is likely, laparoscopic surgeons will encounter this complication in their lifetime. Critical view of safety (CVS) is emphasized enough in literature to prevent BDI. Herein this video presentation we report our own strategies to make the operation safer when it is not possible to get CVS. Methods and Procedures: We present a video presentation describing our approach to difficult laparoscopic cholecystectomy to make it safer. Results: We describe the following strategies in situations where the CVS cannot be identified. In this situation a decision pause should be taken to decide the further plan of action. We propose considering a fundus first cholecystectomy initially. If this is not possible, we suggest three choices: subtotal cholecystectomy, cholecystostomy or abandoning the procedure. Conclusion: Our stepwise approach has proved effective in dealing with difficult cholecystectomy and making the operation safer. ★ Harrith M. Hasson Award for Best Presentation Promoting Education and Training

Objective: To demonstrate the safe and effective minimally invasive technique for enterolysis in the face of dense adhesions, prior to robotic-assisted total laparoscopic hysterectomy. Methods: This is a video case presentation of a 50 yo G2P1011 patient with a history of abnormal uterine bleeding secondary to uterine fibroids. After failing medical management with various forms of progestins she was referred to our center for surgical consultation. Results: A preoperative pelvic MRI revealed a 10 x 7 x 12 cm uterus with multiple hypodense masses in the uterus, the largest measuring 5 x 4.5 cm. The visualized portion of the bowel was normal in appearance. Due to previous failed interventions the patient opted for definitive management via hysterectomy. At surgery there was a dense curtain of omental and bowel adhesions in the upper abdomen, completely obscuring the pelvis. After careful placement of robotic trocars, the adhesions were meticulously taken down with use of sharp and blunt dissection as well as judicious use of energy. Once the pelvis was visualized loops of bowel were noted to be draped over the uterus and adnexa. These adhesions were carefully lysed on their entirety, thus allowing for safe completion of the hysterectomy. Conclusion: A minimally invasive approach to enterolysis in order to facilitate pelvic surgery is safe, effective and feasible even in the face of very dense adhesions. Paying attention to key principles of adhesiolyis can lead to a favorable outcome as was noted in this case.

Objective: The objective of this video is to present the use of robotic-integrated ultrasound in performing a double discoid excision of multifocal rectosigmoid endometriosis. Methods and Procedures: We present a 26 year-old G0 with chronic pelvic pain, dyschezia and dysmenorrhea refractory to medical management who desires future fertility. Her imaging was suggestive of deep infiltrating endometriosis involving the rectosigmoid colon. The intervention performed in the video includes discoid excision of multifocal rectosigmoid deep infiltrating endometriosis with use of robotic-integrated ultrasound. Results: n/a Conclusion: Performing a complete pre-operative evaluation in patient’s with suspected endometriosis is important in determining the extent of disease and the necessity of a multidisciplinary approach. Robotic-integrated ultrasound can provide additional information including size and depth of bowel endometriosis lesions, which can play a role in surgical decision making. Performing a double discoid excision of multifocal rectosigmoid endometriosis with the use of robotic-integrated ultrasound is a technique that can avoid the need for a segmental bowel resection.

Objectives: Minimal invasive surgeries are associated with several advantages but also high costs. Lately, vaginal natural orifice transluminal endoscopic has been a new merging technique in gynecology and gaining more popularity. This study evaluates financial feasibility of outpatient vaginal natural orifice transluminal endoscopic hysterectomy for benign uterine pathology. Methods and Procedures: Retrospective cohort study (Class II-2) of 13 patients who underwent vaginal natural orifice transluminal endoscopic hysterectomy for benign conditions by the same surgeon (T. Nguyen) at the University of Texas Medical Branch, Galveston, TX, USA, during September 2022-January 2023. The study only included cases considered appropriate for outpatient management and pure hysterectomy. Financial costs for patients discharged the same day were compared to 13 consecutive laparoscopic hysterectomy. Results: Twenty-six cases (13 on each group outpatient) were analyzed. Payer types were not different among the groups (p > 0.05). Outpatient hysterectomy was associated with $6,762 average total direct cost in vaginal natural orifice transluminal endoscopic arm compared to $9,370 total laparoscopic hysterectomy. Average direct contribution margin was $6,611 in vaginal natural orifice transluminal endoscopic arm compared to $7,725 in total laparoscopic hysterectomy arm. Conclusion: Financial analysis has revealed vaginal natural orifice transluminal endoscopic has less total direct costs compare to total laparoscopic hysterectomy. However, direct contribution Margin was higher in total laparoscopic hysterectomy arm.

Objective: Report patient first impressions & tolerability experiencing a novel digital speculocolposcopy (DSC) exam compared to conventional vintage colposcopy. Methods and Procedures: Clinical evaluation of 157 patients undergoing new digital speculocolposcopy (DSC) exam compared to conventional bi-ocular colposcopic examination. This compact DSC attaches directly in to the speculum with only a cable leading to a viewing monitor. Post procedure, patients completed Likert scale & “Yes/No” type questionnaire. Areas surveyed included patient’s ability to view the entire exam real-time on video screen; did they enjoy participating & being part of the experience; did they feel more educated about their condition or findings, if any; was there any perceived level of stress/anxiety & were they happy or ambivalent about the experience overall. Finally, as compared to conventional current colposcopy, a “Yes/No” question, if patient would advocate/recommend the DSC experience to a friend. Results: Almost 96% of patients enjoyed visualizing their anatomy and procedure; 94% liked the fact they could participate in the event; 97% felt more educated compared to “old-style colposcopy; participants (93%) remarked about a minimal to none elevated stress/anxiety level during the DSC exam and 96% participants were happy while 3% were ambivalent about their overall experience. Lastly, 98% would advocate this type of colposcopy exam to a friend. Conclusions: Patient reaction to digital speculocoplposcopy compared to conventional vintage colposcopy was overwhelmingly positive.To sum it up in the words of one of the participants, “I don’t need the doctor to tell me everything looks good down there because now I can see it all for myself!”

Objective: To avoid anterior neck scarring, numerous remote-access techniques to approach the thyroid gland have been described, including transaxillary (TA), bilateral axillo-breast approach (BABA), and transoral robotic thyroidectomy (TORT). We aimed to investigate the characteristics of these distinct thyroidectomy approaches. Methods and Procedures: A total of 2351 thyroidectomy cases conducted between 2019 and 2021 were reviewed, including 1973, 281, 66 and 31 patients who underwent conventional transcervical approach (TCA), TA, BABA, and TORT, respectively. Student’s t-test and chi-square test were used for analyzing the data. Kruskal–Wallis and Mann–Whitney U tests were used if normality was not found. Results: Central LNs were retrieved mostly in patients who underwent lobectomy through TORT (mean: 9.4, p<0.001). Metastatic central LNs were found more frequently (mean: 1.9 in lobectomy, 3.7 in total thyroidectomy) in patients who underwent lobectomy through TCA and TORT, compared to other approaches (mean: 1.4, 2.4 respectively, p<0.05). Numbers of retrieved central LNs were significantly lower in the BABA group compared to other groups in lobectomy and total thyroidectomy (mean; 4.8, 6.2, respectively, p<0.05). Total thyroidectomy was performed more frequently in BABA (51.8%) than in the other groups (p=0.005). Conclusions: Owing to differences in working space and direction of surgical field, TA was advantageous for preserving the EBSLN, while BABA was good for total thyroidectomy and excision of large goiters. Therefore, if these characteristics are considered in selecting the best approach, better outcomes can be obtained in terms of cosmesis, function, and recurrence. ★ Medical Educator Consortium Award for Best Scientific Paper

Objective: This educational video presents the surgical management of a rare case of a cervical cerclage bladder perforation. Methods and Procedures: We describe the case of a 52-year-old female who presented with gross hematuria 15 years post prophylactic cervical cerclage placement. This educational video outlines clinical considerations and the endoscopic (laparoscopic and cystoscopic) approach to management. Results: Erosion of a cervical cerclage through the bladder may be successfully managed by minimally invasive surgical techniques. Conclusion: In women presenting with lower urinary tract symptoms who have previously had a cervical cerclage, consider erosion into the bladder as a possible cause. ★ Best Multspecialty Video

The objective of this film is to demonstrate the use of a single-port robotic system to perform a myomectomy through a single incision. Uterine fibroids are an extremely common benign gynecologic condition, and myomectomy is the standard of care for patients desiring preservation of fertility. Single site surgery has the benefit of improved cosmesis and decreased post-operative pain, however single-site laparoscopic surgery is challenging due to instrument clashing, loss of triangulation, and surgeon learning curve. The single-port robot helps overcome some of the challenges inherent in single-site laparoscopic surgery with articulating instruments and camera. Because of its recent introduction, the literature is limited in describing its role in benign gynecologic surgery. This particular patient had known uterine fibroids and desired future fertility as well as a minimally invasive procedure. As demonstrated in the video, the fibroids are able to be excised and extracted with ease, and the defect was able to be closed in 3 layers. She was able to be discharged same-day after the procedure and had comparable blood loss to am equivalent laparoscopic procedure. This demonstrates the feasibility of using the single-port robot to perform benign gynecologic procedures. This is the first known video demonstrating the use of the single-port robot to perform a robotic-assisted single site laparoscopic myomectomy. It seeks to add to the existing literature demonstrating feasible use of the single-site robotic platform to perform benign gynecologic procedures while overcoming common obstacles encountered with traditional single-site laparoscopy such as instrument crowding, clashing, and loss of triangulation.

Objective: Hemangiomas are benign vascular neoplasms rarely found in the gastrointestinal tract, accounting for 7-10% of all benign tumors of the small bowel and 0.05% of all intestinal neoplasms. Unlike other benign tumors, hemangiomas are symptomatic in 90% of cases with the most frequent presentation being chronic gastrointestinal bleeding. We present the case of a 32-year-old male who underwent surgery for acute appendicitis, with incidental intraoperative findings of an asymptomatic terminal ileal hemangioma. Methods and Procedures: We performed a laparoscopic ileocecectomy for resection of both the appendix and the incidentally discovered neoplasm. The specimen was sent to pathology. Results: Preoperative computed tomography scan revealed evidence of acute appendicitis (Figure 1). Intraoperatively, the appendix appeared inflamed (Figure 2). A 2x2cm indurated transmural polypoid mass was noted in the terminal ileum 5cm proximal to the ileocecal junction (Figure 3). Pathology was not available for frozen section. To achieve grossly negative 5cm margins in case of malignancy, an ileocecectomy was indicated. This was performed laparoscopically with a primary stapled ileocolonic anastomosis. Histopathology of the resected specimen (Figure 4) revealed acute appendicitis, and a transmural hemangioma of the terminal ileum with involvement of the pericolonic fat. Conclusion: Surgical resection is the mainstay of treatment for symptomatic small bowel hemangiomas. Although these are frequently symptomatic, our case demonstrates the unusual finding of a completely asymptomatic and incidentally found lesion. Given its size and transmural involvement, there was potential for future complications such as hemorrhage, obstruction, intussusception, and perforation. Resection was curative, and the patient recovered uneventfully.

Objective: Calcific aortic valve disease is the most common valvulopathy in developed countries. Aortic valve replacement (AVR) is currently the sole effective treatment for AS and is traditionally performed using a full sternotomy (FS). AVR can now be done via a minimally invasive (MI) approach, which has shown to reduce surgical trauma. This case report aims to emphasize the advantages of minimally invasive surgery (MIS) for AVR. We would like to discuss current trends involving mechanical vs biological valves in young adult patients. Case Report (Methods): 49 year-old male athlete with severe AS secondary to a type 1A bicuspid aortic valve. This patient sought out MIAVR, declined anticoagulation and wished to resume physical activities swiftly. To reduce the likelihood of requiring surgical AVR at an advanced age, we recommended a bioprosthetic valve made from bovine pericardial tissue, intended to facilitate valve-in-valve procedures in the future. Results: MIAVR was performed via a right anterior minithoracotomy (RT) approach. He was discharged on pod#3 and made a prompt recovery, resuming an exercise routine within a month. Conclusion: MIAVR has emerged as a safe and effective technique with favorable outcomes including reduced morbidity and mortality, blood loss, recovery time, hospital stay, and cost. Compared to FS, the RT approach has been linked to a reduction in postoperative atrial fibrillation and blood transfusions. In the advent of valve-in-valve procedures, the use of bioprosthetic valves in younger patients with AS is a reasonable alternative to mechanical valves. Selection of valve should involve shared decision-making process.

Objectives: The development of advanced endoscopic simulators has paved the way for training in more complex endoscopic procedures like ERCP. Recent technological advances have made telementoring in surgical education more available and applicable. Primary objective was to assemble low-cost telementoring system with minimum latency and zero artifacts using existing commercially available technologies, thus ensuring the adoption of the proposed solution from the global medical community. Validation of the system was made by using international experienced mentors as it has been suggested that higher endoscopist case-volumes are associated with safer ERCP and successful outcome. Methods: To assemble our telementoring hardware we used off-the-shelf available components in the local market. The web camera was set to view the mentee hands and, together with the monitor image, they were simultaneously transmitted to the mentor. Two of the co-authors acted as remotely located mentors to five Greek surgical residents. Three ERCP cases were assessed in a surgical simulator namely bile duct stone removal (ERCP I Case study 4), hilar stenosis (ERCP I, Case study 2) and cystic leakage (ERCP II, Case study 4). Results and Conclusion: The total cost of the assembled system was in the range of less than 1.500,00 €. It has been shown that the telementoring assembly was efficient, accurate and without any latency. Thus, we may suggest its use to other simulation centers since it is an easy, cost efficient, plug n play set up that can be used as a telementoring platform using VR simulators in advanced Endoscopic and MIS techniques.

Objective: Anastomotic leaks (AL) are the most devastating complications of colorectal surgery with significant increase in mortality, morbidity and cost. Many efforts are put in researching methods to reduce their rates. Fluorescent angiography with indocyanine green (ICG) is a novel technique used in recent years. Because there was no such previous practice in our country we developed and introduced a protocol for perfusion assessment with ICG during minimally invasive rectal cancer surgery Methods and Procedures: We developed a protocol for fluorescent angiography and prospectively followed up the patients. Primary outcome studied was AL rate after rectal resection. We also studied the time for fluorescence to appear in the bowel wall, transection line change rates and stoma formation rate. Results: From June 2020 to June 2022 a total of 53 colorectal resections were performed by a single surgeon. Of them 25 were robotic and 28 laparoscopic. AL rate was 0% (compared to 5,76% previously), mean time to fluorescence was 30.92 ± 10.288 sec, transection line was changed in 9 patients (17%) and stoma was formed in 17 (32%). In the statistical analysis no statistically significant correlations between variables were found. Conclusion: Fluorescent angiography with ICG was feasible and successfully applied in the surgical practice. The results show positive impact from the method on AL rates.

Critical limb ischemia represents a very severe problem for those who suffer from it. With the advent of endovascular surgery, it has become a first-line therapy for the treatment of these patients because it is minimally invasive. Endovascular therapies procedures are increasingly successful, however, studies have reported that almost half of the patients treated by this means are not candidates because they present very extensive lesions of the vessels, due to this, even patients are ruled out for undergoing an endovascular procedure. Open revascularization surgery represents a high rate of major amputation. In order to safeguard the extremities of patients, there is a new technique on the rise that is deep vein arterialization. This technique is not performed in all centers since it is still in development and depending on the center and the available materials it is modified. Several small case series have reported high rates of wound healing with this method. In this poster we present our technique with the resources available at our hospital.

Although there is discussion about the opportunities in “telesurgery”, there are numerous non-medical technologies which are required to make telesurgery possible on a routine basis. This includes the new 5G and emerging 6G telecommunications, Edge Computing, Big Data, Computational Analytics, Supercomputing, and Artificial Intelligence to name a few. This infrastructure is currently beginning implementation and globally over the next 5-1 years. Although these technologies will be implemented during this time frame, what is entirely unknown is whether remote telesurgery will be practical, safe, cost effective and other significant non-technical issues.

Objective: We present a case of a 68-year-old male with a history of von Willebrand’s disease type II and a four-month progressively painful, and initially reducible right inguinal hernia. The objective was to repair the hernia and intervene on other intraoperative findings when necessary. Methods: The patient underwent an elective robotic repair of a right incarcerated inguinal hernia with a sac encasing the bladder and preperitoneal fat. Subsequently, the patient was discovered to have an asymptomatic left inguinal hernia with a cord lipoma, incarcerated sigmoid colon, and epiploic appendagitis. A transabdominal peritoneal flap was created to insert polypropylene meshes and prevent future herniation of abdominal contents. Fibrin sealants, cautery, and blunt dissection were utilized throughout to proactively address the patient’s predisposition to bleeding. Results: The patient was admitted to the inpatient floor for recovery and had an uneventful postoperative course. On postoperative day three, the patient was hypotensive with a low hemoglobin, and one episode of fall accompanied by nausea and vomiting. After receiving a normal saline fluid bolus, the patient became normotensive, and was discharged. At a follow-up appointment, he had a scrotal hematoma likely due to intraoperative intrabdominal bleeding, which also self-resolved. Conclusions: Ultimately, clinicians must remain aware of potentially bilateral inguinal hernia repairs and use judgment to determine safe and effective approaches. Bladder incarceration is uncommon in inguinal hernias but can be increasingly painful. Contrarily, epiploic appendagitis can present asymptomatically as a rare finding. Postoperative complications from such a procedure are likely minimal, but require comprehensive and periodic monitoring.

Objective: Evaluate the success of medical versus surgical management of patients with interstitial ectopic pregnancies, evaluate possible surgical complications of a wedge resection, and evaluate outcomes of future pregnancies. Methods and Procedures: Retrospective study cohort study of pregnancies with a history of interstitial ectopic pregnancy from 2016 to 2022 at two large tertiary hospitals in the New York Long Island area. Basic demographics, details on medical or surgical treatment, and any available pregnancy outcomes were collected. Results: Thirty-nine cases of interstitial pregnancy were identified. Ten patients (25.6%) were initially treated conservatively with intramuscular methotrexate with seven of these patients (70%) requiring surgical intervention after increasing or plateau serum human chorionic gonadotrophin. Surgical intervention of cornual wedge resection was performed on 37 patients (75.4%) and included thirty-five laparoscopic (94.5%) and two laparotomies (5.5%). Fifteen patients had confirmed pregnancies following treatment of interstitial ectopic pregnancy. There was one subsequent fallopian tube ectopic pregnancy, two fetal demises, and eleven live births. Of the live births, eight of these deliveries were term (72.7%) and three were preterm deliveries (27.3%). There were eight cesarean deliveries (72.7%) and three vaginal deliveries (27.3%). There were no cases of abnormal placentation. There were no cases of uterine rupture. Conclusion: Medical treatment of interstitial ectopic pregnancies was largely unsuccessful. As expected, cornual resection via laparotomy was associated with higher estimated blood loss. Following successful treatment, future pregnancies are possible with both cesarean and vaginal mode of delivery.

Objective: Management of Proximal Ureteral stricture with ureterocutaneous fistula by appendicular substitution ureteroplasty. Methods and Procedure: Management of long segment proximal ureteral stricture has been a challenging scenario as it may necessitate substitution. The available literature shows vermiform appendix anastomosed in an anti-peristaltic fashion is a suitable substitute. A 66 yr. old diabetic female presented with persistent urine leak from right flank following right laparoscopic converted to open ureterolithotomy for a 2 cm proximal ureteric calculus done elsewhere. Leak persisted after PCN insertion. Contrast MRI showed 2 to 3 cm proximal ureteral stricture and 1 cm wide ureterocutaneous fistula. Laparoscopic exploration and proceed was done. Ports placed by triangulation technique. Dense pannus noted ureter. Approximately 4-5 cm of proximal unhealthy ureter was excised. Appendix was inspected for health and long vascular pedicle. Appendix was mobilized and cut. Lumen was calibrated with 5 Fr IFT to confirm patency. Later appendix was anastomosed in a watertight fashion replacing proximal ureter. Ureter and Kidney was retroperitonialised. Ports placed by triangulation technique. Dense pannus noted ureter. Approximately 4-5 cm of proximal unhealthy ureter was excised. Appendix was inspected for health and long vascular pedicle. Appendix was mobilized and cut. Lumen was calibrated with 5 Fr IFT to confirm patency. Later appendix was anastomosed in a watertight fashion replacing proximal ureter. Ureter and Kidney was retroperitonialised. Post operative period was uneventful. Patient was discharged on POD – 3. HPE showed Non-specific inflammatory changes. Results: Patient followed up with MRI at 6 months and DTPA at 1 year which showed good drainage. Conclusion: In this era of minimally invasive surgery, laparoscopy made us revisit and extend substitution to proximal ureteral stricture with good outcomes. This is the one of the few cases using minimally invasive technique where appendicular substitution ureteroplasty is done for proximal ureteral stricture with ureterocutaneous fistula.

Objective: This video presentation demonstrates a combined case of a robotic right colectomy with intracorporeal anastomosis and a partial hepatectomy. This case highlights the innovative surgical technique utilizing robotic surgery. Methods and Procedures: This is a case of a 61-year-old female with metastatic transverse colon adenocarcinoma with liver metastasis who underwent neoadjuvant chemotherapy which consisted of ModFOLFOX and Bevacizumab. She subsequently underwent a robotic right colectomy with intracorporeal anastomosis, robotic partial hepatectomy of segments V and VI, and a robotic cholecystectomy. Results: The patient recovered well post-operatively and was discharged home on post-operative day 3. The final pathology revealed residual colonic adenocarcinoma, all margins were negative for carcinoma, and forty-three lymph nodes were negative for tumor. The pathologic staging was T3N0M1a. Conclusions: Herein we discuss the complexity of a metastatic transverse colon adenocarcinoma with liver metastasis and provide a video demonstration of a minimally invasive approach with the use of robotic surgery. Simultaneous colon and liver resections for metastatic colon cancer have been described in the literature but are not frequently performed. This video presentation showcases the capabilities of robotic surgery and innovative surgical technique of this interesting case.

Objective: To highlight the multidisciplinary coordination and minimally invasive approach for GIST resection in cirrhotic patient. Method and Procedures: 59-year-old female with a history of class III obesity, cirrhosis with portal hypertension, esophageal varices, and an asymptomatic 4 cm endophytic GIST in the gastric fundus. The patient was referred to Transplant Hepatology for medical optimization, and it was decided to perform a transjugular intrahepatic portosystemic shunt (TIPSS) procedure before tumor resection. After the patient was optimized, it was decided to proceed with a laparoscopic intragastric fundus GIST resection. Results: An incision was made at the greater curvature of the stomach. Two 3-0 silk stay stitches were placed in the gastrotomy and were brought out through the ports. A 12mm balloon-tipped trocar was inserted into the gastrotomy and inflated with the stay sutures under traction. An upper endoscopy was performed, two radial expanding ports were placed into the stomach on either side of the 12-mm port. 45 mm Blue staple loads were then used to staple the normal stomach outside the tumor. Once the tumor was resected, the gastrotomy was closed with no complications. Diet was advanced gradually, and the patient was discharged on postoperative day 3. Pathology revealed a low-grade 4.5 cm GIST and negative surgical margins. TIPSS was left open and was not associated with any complications. The patient has been doing well on follow-up visits and denies any symptoms. Conclusions: Using a transgastric approach for GIST resection in cirrhotic patients is feasible, safe, and effective after decompression of gastric varices with TIPSS.

Objective: Since the FDA ban in 2019 on sale and distribution of surgical mesh for treatment of anterior compartment prolapse in women with pelvic organ prolapse (POP), there has been a resurgence of interest in native tissue repair (NTR) as an alternative approach. Although many of these surgical techniques such as sacrospinous ligament fixation (SSLF-Richter) has been previously described in the literature (Delacroix et al., 2022), their long-term anatomical and functional results are somewhat unknown and further studies are required to draw more definite conclusions on their suitability and efficacy in treatment of POP. The purpose of this presentation will be to review and assess the current literature within the past 10 years on the use of native tissue repairs versus transvaginal mesh for anterior compartment defects and to provide evidence-based recommendations on safety and durability derived from recent data analysis. Methods: The question as to whether native tissue repairs can be considered as effective as vaginal mesh in anterior compartment prolapse will be addressed in the context of long-term anatomical success rates, minimal re-operative recurrence rates and overall patient satisfaction as measured by QoL indicators. Results: In recent randomized controlled trials (RCT) comparing polypropylene mesh inlays or biological xenografts with NTR, there was no additional benefit found at mid-term follow-up of four to six years post operative and mesh inlays may possibly have even worse patient outcomes. (Reid et al., 2023) Conclusions: Native tissue repairs can be considered as safe and effective treatment for POP, however, RCTs are still needed to address long-term follow-up.

Objective: Hysteroscopy represents the gold standard for the diagnosis and treatment of intracavitary uterine pathology, it is rarely associated with complications but 50% of them are associated with uterine cavity entry. The false passage occurs when the dilator enters the cervical muscle fibers, and it is correlated with early procedure termination or abortion. The objective is to educate about this pathology and to describe the different management techniques. Methods: This is a review of the literature on diagnosis and management of false passage, and a video presentation of an innovative technique for hysteroscopic intracervical bridge division. Results: False passage was diagnosed during operative hysteroscopy, using the hysteroscopic scissors the intracervical bridge was successfully divided, uterine cavity access was achieved and hysteroscopic polypectomy was completed. Conclusion: False passage can occur during cervical dilation due to several factors. Early procedure termination might happen due to high fluid deficit and concerns of uterine perforation. Prevention and management of this pathology should be approached in a stepwise manner. Multiple techniques have been explored for management, hysteroscopic division of cervical bridge with scissors represents an easy and readily available technique to decrease the early hysteroscopic termination and abortion rate.

Objective: The uterine arteries mainly originate from the anterior division of the internal iliac artery, but also have many anatomical variations in their origin. Knowledge of these variations is crucial for transcatheter arterial embolization, during hysterectomies and in many other obstetrical and gynecological procedures. The purpose of this study was to investigate the prevalence of variation in uterine artery origin and its clinical significance in global patient populations through a meta-analysis of pertinent literature including imaging and surgical studies. Methods and Procedures: We pooled literature data detailing uterine artery origin prevalence rates and calculated pooled prevalence rates. Data searches and analyses were performed according to Anatomical Quality Assurance and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: There were 6 radiological studies and 3 surgical studies analyzed representing a total of 1246 uterine artery origins. The meta-analysis demonstrated the highest prevalence of Type I (originating as the first branch of the inferior gluteal artery) origin of the uterine artery in both surgical and radiological studies, 46.6% and 41.8% respectively. Type IV (originating as first branch of the internal iliac artery) origin was the next prevailing type with 17.9% prevalence in radiological studies followed by Type III (originating as trifurcation with inferior and superior gluteal arteries) origin with 14.7% prevalence in surgical studies. Conclusion: Understanding the different variations of the uterine artery decreases the risk of iatrogenic injury especially in patients with challenging anatomy. This meta analysis outlined the exact prevalence in different uterine artery origins. ★ Michael S. Kavic Award for Best Scientific Paper by a Resident

Introduction: Old age is a predictor of increased morbidity following pancreatic operations. This study was undertaken to compare the peri-operative variables between robotic and ‘open’ pancreaticoduodenectomy, in patients ≥80 years of age. Methods and Procedures: Since 2012, with IRB approval, we retrospectively followed 69 patients ≥80 years of age who underwent robotic (n=42) and ‘open’ (n=27) pancreaticoduodenectomy. Statistical analysis was undertaken using chi-square test and Student’s t-test. Data are presented as median(mean±SD), and significance accepted with 95% probability. Results: Patients who underwent the robotic approach had a greater Charlson Comorbidity Index [6(6±1.6) vs 5(5±1.0), (p=0.01)] and previous abdominal operations [n=24 (57%) vs n=9 (33%), (p=0.04)]. The robotic approach led to longer operative time [426(434±95.8) vs 240(254±71.1) minutes, (p<0.0001)], decreased blood loss [200(291±289.2) vs 426 (434±95.8) mL (p=0.008)], and decreased intraoperative blood transfusions (p<0.05). Serious postoperative complication rate (Clavien-Dindo ≥III) was not different between approaches (p=0.29). Length of hospital stay [7(9±6.0) vs 10(13±11.1) days] was shorter for patients that underwent robotic pancreaticoduodenectomy (p=0.04). Conclusion: Patients who underwent robotic pancreaticoduodenectomy were more likely to have less favorable demographic history yet produced comparable and at times superior outcomes. This study indicates that robotic pancreaticoduodenectomy offers the same benefits for patients of advanced age as purported for younger patients and demonstrates age should not preclude robotic operations and their salutary benefits.

Objective: Identifying risk factors for postoperative complications is important for predicting patients’ long-term health outcomes. We investigated preoperative diabetes mellitus (DM) as a risk factor for postoperative outcomes after robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy. Methods and Procedures: We retrospectively analyzed consecutive patients who underwent RAVT pulmonary lobectomy over a 93-month period by one surgeon. Occurrences of postoperative complications were analyzed in 500 study patients. Statistically significant (p≤0.05) differences between groups were determined by Chi-square/Fisher’s exact analysis or Wilcoxon Rank-Sum (Mann Whitney U test) for medians. Results: Among patients undergoing RAVT pulmonary lobectomy, 17.2% had preoperative DM. Postoperatively, patients with preoperative DM were more likely to have atrial fibrillation (p=0.011). Patients with preoperative DM were more likely to have squamous cell carcinoma and neuroendocrine carcinoma, while patients without were more likely to have adenocarcinoma (p=0.021). Patients with preoperative DM were less likely to have cancer spread to one or more lymph nodes (p=0.001). Finally, patients with preoperative DM had significantly longer hospital length of stay (p=0.042), and significantly decreased median overall survival time (p=0.048). Conclusion: Patients with preoperative DM were found to have more incidences of postoperative atrial fibrillation, a longer hospital length of stay, and decreased median survival time. Patients with preoperative DM have significantly different cancer histologies than patients without preoperative DM. Therefore, preoperative DM is a risk factor for postoperative atrial. ★ Paul Alan Wetter Award for Best Multispecialty Scientific Paper

Objective: Currently hernias are repaired using either open or minimally invasive surgical approaches 2 . Laparoscopic repair of inguinal hernias in obese patients have been shown to have comparable perioperative complications to open repair 4 . However, few studies evaluate the safety of robotic repair in obese populations 5 . This study compares outcomes after robotic inguinal hernia repair between non-obese and obese patients and aims to evaluate the safety of robotic inguinal hernia repair in an obese population. Methods and Procedures: Prospectively collected data from February 2019 to July 2022 was retrospectively reviewed. A total of 76 patients were found to have undergone robotic inguinal hernia repair and were included. Patients were sorted into two groups based on BMI, using BMI under 30 kg/m2 and BMI greater than 30 kg/m2. Patient age, gender, length of hospitalization (LOH), estimated blood loss (EBL), operative time, and recurrence rates were compared. Statistical analysis was performed with Chi-square tests and non-parametric Mann Whitney U Test where appropriate. Results: Results show no significant difference between LOS, EBL, operative time, percentage of total risk factors, 12 month recurrence, and 24 month recurrence (p = 0.001). Conclusion: Robotic platforms are a developing platform in minimally invasive surgery which can offer advantages over conventional laparoscopy in robotic inguinal hernia repairs4. This study provides evidence that robotic inguinal hernia repair in obese patients have comparable postoperative complications to non-obese patients.

Objective: Uterine fibroids are the most common benign gynecologic tumors in reproductive-aged women but vary in presentation from incidental findings to bulk symptoms and mass effect. We present a video review of a 32-year-old female with acute onset lower extremity pain and difficulty ambulating, found to have a large uterine fibroid causing compressive neuropathy and motor dysfunction requiring gynecologic surgical management. This video review demonstrates the need for urgent laparoscopic myomectomy. Methods/Procedures: This is a surgical video review from a large urban academic institution of a patient who underwent a laparoscopic myomectomy. Four laparoscopic ports were used including three 5mm ports and one 30mm port. Results: This 32 year-old who presented with lower extremity neuropathy and motor dysfunction was found to have a large posterior uterine fibroid causing lumbar plexus and obturator nerve compression. She underwent an uncomplicated laparoscopic myomectomy and had resolution in her motor dysfunction and significant improvement in her neuropathy. She did well postoperatively and was discharged home. This rare case demonstrates the need to have a high suspicion for uterine fibroids causing compressive neuropathy from mass effect requiring urgent evaluation and surgical intervention to prevent long-term sequelae. Conclusions: Large pelvic masses causing compressive mass effect should be considered on the differential diagnosis for the etiology of non-gynecologic symptoms such as neuropathy, requiring urgent gynecologic evaluation and possible surgical management that can be performed with minimally invasive technique.

Objective: We operated on a series of mostly obese patients with diastasis recti abdominis using the “Slim-Mesh” technique to repair/reinforce the diastasis and linea alba/recti muscles without plicating and traumatizing them. Additional objectives were to decrease operation time and intra- and postoperative complications. Methods and Procedures: We considered T1 cases diastasis after pregnancy and T2 cases obesity (BMI > 30 mg/kg 2 ); D1, D2 and D3 when the diastasis measured 2-3 cm, 3-5 and >5 cm respectively; H0 and H1 without and concomitant umbilical and/or epigastric hernia respectively. At our Department, between May 2010-November 2022, 47 patients with diastasis recti were operated on with the “Slim-Mesh” technique to reinforce/repair the traumatized linea alba/recti muscles, without plicating them. This was a prospective (83%)-retrospective study. Results: We studied 23 males and 24 females. Mean age and BMI was 58 years and 29 kg/m 2 respectively. Groups D1, D2 and D3 comprised 6, 23 and 18 patients respectively; groups T1, T2, H0 and H1 comprised 24, 25, 13 and 34 patients respectively. Mean operation time for all cases was 100 minutes. Mean length of hospital stay was 2.3 days and follow-up time was 5 years. We had 6 late postoperative complications: 3 hernia recurrences and 3 trocar-site hernias. Conclusion: Considering the lack of agreement on the best surgery for diastasis recti repair, in our experience the “Slim-Mesh” technique is a valid way to save, repair and reinforce linea alba/recti muscles in diastasis patients, including the obese population (53%).

Objective: To present the successful surgical management of unilateral congenital hydrosalpinx in an infertile patient Methods and Procedures: We present a case of a 27 year old female with a history of PCOS presenting with 2 years of primary infertility despite successful ovulation induction with Clomiphene Citrate. Hysterosalpingogram suggested a left hydrosalpinx which could have contributed to failure to conceive. Lack of history of pelvic inflammatory disease, family history or clinical manifestations of endometriosis or history of abdominal surgery suggested that the hydrosalpinx was most likely of congenital etiology. Left congenital hydrosalpinx was confirmed laparoscopically. Unilateral distal neosalpingostomy of the congenital hydrosalpinx was then performed, thus preserving the left fallopian tube. Patient had 6 months of postoperative follow up. Results: The patient conceived with the first cycle of ovulation induction, however pregnancy was terminated when found to be a partial molar pregnancy. Patient is currently attempting conception again. Conclusion: Elimination of the effects of a unilateral hydrosalpinx after successful distal neosalpingostomy in patients with congenital hydrosalpinx may improve the pregnancy rates during ovulation induction or natural conception. Neosalpingostomy, when patients are properly selected, may enhance chances of spontaneous conception every cycle, thus avoiding the need for In Vitro Fertilization in such patients.

Objective: To review current literature on retained foreign objects and discuss surgical techniques for retrieval of a retained suture needle with an obliterated anterior and posterior cul de sac. Methods and Procedure: Case report of a 43 year-old female with chronic right lower quadrant pain, endometriosis, and extensive surgical history was found to have a retained foreign object (suture needle) 5 months after she underwent a robotic-assisted laparoscopic left oophorectomy, extensive lysis of adhesions, retroperitoneal dissection, left ureterolysis, and uterosacral biopsy for a symptomatic complex left adnexal mass. Pathology was benign. Results: Patient presented to the ED and CT abdomen and pelvis showed a 7 cm peritoneal inclusion cyst and a surgical foreign object in the left hemipelvis. A follow up abdominal x-ray showed a radiopaque structure suspicious for a retained suture needle. She underwent a robotic-assisted laparoscopic removal of a retained suture needle, resection of peritoneal inclusion cyst and lysis of adhesions by gynecologic oncology. The surgery was complex due to significant bowel adhesions and a obliterated anterior and posterior cul de sac. Conclusion: Retained foreign objects during minimally invasive surgery is rare but can have life threatening complications. Expert surgical skills and appropriate preoperative imaging are necessary for successful retrieval. ★ Best Gynecology Video

Choledochal cysts are rare anomalies of the biliary tree that are most commonly present in children. The management is difficult and requires early resection. In adults, we try to excise all the dilated ducts to prevent malignancy - which usually starts in the 3rd to 4th decade of life. We present a case of type IVa choledochal in a 29 year old man. In the operating room, we excised all the extrahepatic bile ducts while doing the pancreaticoduodenectomy. There was extensive inflammation along the bile ducts including the intrahepatic gallbladder. The pancreatic head was small and atrophic with a less than 1 mm main pancreatic duct. The Surgery took 9 hrs, with 700 ml EBL. He remained tachycardic post op, resolving in 7 days was discharged to home 7 days later. Day 3 he received 2 units of blood transfusion. A repeat CT scan did not show any collections. JP drain had minimal amylase and no bile in it. The drains were sequentially removed. The pathology of the gallbladder revealed severe chronic and focal mild acute cholecystitis, focal metaplastic changes of the gallbladder epithelium but no evidence of dysplasia. The cyst showed an abnormal connection of the pancreatic and common bile ducts, but no evidence of dysplasia or neoplasia Type IVa choledochal cysts are a scarce entity. There is no consensus in managing them in adults. We recommend a pancreaticoduodenectomy with surveillance and possible liver transplant for extensive intra and extra hepatic choledochal cyst with preserved hepatic function.

Objective: A technique is proposed to ameliorate the severe side effects from a classic Duodenal Switch or SADI (Single Anastomosis Duodeno-ileostomy) that may lead to severe hypoproteinemia, micronutrient deficiencies, malnutrition, malodorous stools and diarrhea. A duodenal bipartition is presented. Methods and Procedures: A side-to-side duodeno-ileostomy is accomplished using linear magnets covered by titanium, delivered both trans-orally by flexible endoscopy, sequentially, while laparoscopic assistance provide adequate ileum measurements with titanium markings at 250 cm from the ileo-cecal valve. Results: A 47 y.o. female had a previous sleeve gastrectomy (in 2018 = 311 lbs, and BMI of 47.3 kg/m2), with several co-morbidities like Degenerative Disk Disease and Asthma. After rapid weight loss, she had an abdominoplasty, and 4 years later, a second stage procedure (BMI of 31.0 kg/m2), a side-to-side duodeno-ileostomy, uniting the lower first duodenum with the ileum, antecolic, is performed. The whole procedure is normally completed in 30-60 minutes under general anesthesia, and patients are discharged after a stay of less than 24hours.The delayed compression anastomosis may decrease risks of bleeding and leak, as after 2-4 weeks, magnets will pass. Conclusions: This procedure is feasible and safe. Advantages are the reversibility, partial passage in the natural duodenum for possible ERCP if needed, permits greater absorption of minerals and vitamins, less side effects and offers a possible conversion to full SADI (Single Anastomosis Duodeno-Ileostomy) or Duodenal Switch if needed