Abstracts from the 29th International Congress of the European Association for Endoscopic Surgery (EAES), Barcelona, Spain, 24–27 November 2021

Introduction: Transaxillary thyroidectomy is a demanding surgical procedure, which requires a long learning curve, due to its technical challenges, as well as a trained and experienced team in endoscopic surgery. Material and Methods: A video of a transaxillary thyroidectomy with a technical variance: the approach through the two branches of the ECM muscle. Results: Demonstration of a change to the transaxillary endoscopic thyroidectomy technique (supra-medial approach to ECM) that arose from the need for better visualization of the recurrent laryngeal nerve (NLR)—Fig. 1 , and the postero-medial region of the thyroid, in a highly experienced working group, with more than 150 transaxillary approaches successfully carried out. The surgical procedure was performed through this gap, allowing a better identification of the structures and a consequent increase in their safety. Discussion: As the surgical team gains experience, and taking advantage of the anatomical variability of each patient, there may be a need for adjustments to the technique described, in order to improve the procedure and increase its safety.

Aim: Show the approach to achalasia in rare contexts Methods: description of 2 cases in video presentation Results: Case #1: 64-year-old female suffering from esophageal perforation during endoscopic process to whom a suture, Heller myotomy and Dor fundoplication were applied. Case #2: a 66-year-old male with personal pathological history of alcoholic cirrhosis Child B9 with several decompensations to whom a TIPS procedure for his esophageal varicose veins was associated before the surgical procedure (Heller myotomy and Dor fundoplication) Conclusions: It is mandatory to individualize the approach and surgical strategy to the special circumstances of each patient to carry out the procedures satisfactorily

INTRODUCTION: Mesenteric cysts are rare intra-abdominal benign tumors. They commonly originate from the small bowel mesentery, although a proportion has been found to originate from the mesocolon (24%) and retroperitoneum (14.5%)0.1 They are a rare cause of abdominal pain and are discovered incidentally. If symptomatic, the most common presenting complaint is abdominal pain (55–82%), followed by the complaint of an abdominal mass (55–61%) and the sensation of abdominal distention (17–61%). Diagnosis is extremely difficult since its symptomatology can resemble any abdominal disease.2performing physical examination and conducting radiological investigations such as ultrasonography (USG) and CT are the key to the diagnosis. Surgery is the treatment of choice, as a complete resection with negative borders is curative and prevents recurrence.3 We present a case of a 31-year-old patient, large cystic mass was identified in her lower abdomen. After proper evaluation and surgery patient successfully recovered. The large simple mesothelial cyst was the final diagnosis. CASE REPORT The patient is a 31-year-old female patient, medically free, mother of 2 children, referred to general surgery clinic due to CT scan finding of a large pelvic cyst, for further evaluation. She was complaining of vague on and off abdominal pain, mainly epigastric, lower abdomen, and pelvic area for three months. She had a history of abdominal distention with no other abdominal symptoms nor had a history of abdominal trauma. No H/o weight loss. On examination: there was a swelling in the lower abdomen felt. All blood investigations including the tumor markers were within normal limits including CA 19–9, CEA, alpha-fetoprotein, and CA 125. CT scan report brought from outside and suspect of lymphangioma. MRI showed a large non-enhancing fluid intensity area occupying the pelvic and lower abdomen approximately 7.4 cm * 13 cm * 40 cm sized, a clear fluid containing lesion in the peritoneal reflection (within the peritoneal cavity). It causes displacement of the small bowel loops superiorly. The outline is flabby, with no septations or mural nodules. There is an extension of the cyst into the right side of the pelvic and abutting the right ovary, however, it appears to be separated from ovarian tissue. No focal lesion is seen in retro-peritoneal. There was no solid component representing lymphangioma. Possibility of the omental cyst to be considered. Decision made to do laparoscopic exploring and cystic resection. During the operation, a large peritoneal cyst has been evaluated located in the lower abdomen, attached to the anterior abdominal wall, pelvic and to the dome of the urinary bladder. The cyst separated from its attachment by using the LigaSure energy source. Cystic fluid aspirated and sent to the cytopathology lab which showed a result of negative for malignancy. After full aspiration of the fluid, the cyst is completely extracted through 10-mm trocar, specimen sent to pathology which showed a simple mesothelial cyst. CONCLUSION: A mesenteric cyst is a rare intra-abdominal tumor, present with varied and non-specific, from asymptomatic patient to severely ill patient with peritonitis, perforation and death. Mesenteric cyst must be considered in the differential diagnosis of a cystic lesion within the abdominal cavity. Ultrasonography and CT are the most useful imaging modalities for diagnosing mesenteric cysts. The treatment of choice of mesenteric cyst is surgical resection for both benign and malignant cysts. Complete surgical excision is the treatment of choice. Following surgery, the prognosis is excellent and recurrence is low. Laparoscopic resection has a high success rate with a low incidence of postoperative complications. There are nice Intraoperative Laparoscopic pictures and CT scan, MRI and Histopathology Pictures.

Objective: Coined in 1986, ‘minimally invasive’ was (and is) used to describe procedures that involved making very small (or no) incisions for the surgical treatment of illness and anatomic pathologies that were traditionally treated using open (or more invasive) approaches. Here, we sought to examine changes in the surgical literature as a means of probing and quantifying the adoption of this innovation, split by procedure, organ, and procedure type. Methods: Our analysis focused on 8 broad categories: biliary surgery (cholecystectomy, common bile duct exploration, cholecystojejunostomy), foregut surgery (Nissen fundoplication, paraoesophageal hernia, heller myotomy, partial gastrectomy, peptic ulcer disease, gastrojejunostomy), enteral access (gastrostomy [T-fastener’s technique], Janeway Permanent gastrostomy, jejunostomy), obesity surgery (Roux-en-Y gastric bypass, adjustable gastric banding), solid organ (hepatic resection, adrenalectomy, distal pancreatectomy, splenectomy, nephrectomy), thoracic (pulmonary wedge resection, esophagectomy), hernias (transabdominal preperitoneal repair [TAPP], totally extraperitoneal repair [TEP], ventral), and colorectal (right colectomy, left colectomy, low anterior resection [LAR], abdominoperineal resection [APR], appendectomy). Our primary outcomes were: (a) the count / fraction of total annual published literature, clinical trials (including randomly controlled trials), and reviews (including meta-analyses and systematic reviews) focused on the description or analysis of minimally invasive approaches, further split by laparoscopic versus robotic qualifiers; and (b) the time (in years) to the fraction of minimally invasive articles reaching 50% of the total. Results: Among the 8 categories and 30 procedures, biliary, foregut, and obesity surgeries had the highest and quickest rate of adoption of minimally invasive techniques. At its peak, 67.5% of cholecystectomy articles published in a single year (1997) described or mentioned laparoscopic approaches, as did 72.0% of articles about Nissen fundoplication (2002). Solid organ and thoracic procedures appear to lag behind; at its peak, only 15.3% of articles in 2020 relating to hepatic resection included or mentioned laparoscopic approaches; adrenalectomies had the largest fraction of all solid organ procedures at 37.8% (in 2011). Similarly, at its zenith, only 4.3% of articles about pulmonary wedge resections in 2014 included, in part, laparoscopic approaches, as did only 12.4% of the esophagectomy literature (2012). Hernia repair and colorectal procedures were more evenly split with, roughly half the literature describing or relating to minimally invasive techniques at their peak. More globally, we noticed two general trends to adoption of minimally invasive approaches: (a) either a quick inflection point in which virtually all the literature appears to switch focus overnight (e.g. cholecystectomy), or (b) a more linear/slow rise as observed with solid organ or thoracic surgeries (e.g. adrenalectomy). Quantitatively: In 1989, 2.3% of cholecystectomy literature described or analyzed laparoscopic approaches, when contrasted to only 3 years later (1992), when the fraction jumped to 51.9% of all articles. In comparison, the adoption of laparoscopic approaches in the adrenalectomy literature was linear, increasing from 5.8% in 1993 to 30.3% in 2003, at a rate of 2.5% per year for that decade. Conclusion: Understanding the trends in literature as a proxy for integration of minimally invasive techniques into surgical practice is the first step to illuminating the hurdles for adoption of surgical innovation (including minimally invasive and robotic approaches). As we have shown, adoption of minimally invasive techniques can be classified into two broad categories. Interrogating the factors that drive these differences in adoption profiles will shed insight into how best to develop and promote future surgical innovations.

Aim: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in combination with systemic chemotherapy is a bidirectional novel treatment approach for patients with peritoneal metastasis who do not meet the criteria for cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Methods: This is the case of a 50-year, otherwise well-being man, referred in July 2018 to our hospital with evidence of advanced occluding rectal cancer and peritoneal metastasis. The patient was presented to the multidisciplinary tumor-board: given the extent of disease a diverting colostomy was placed and successively a systemic neoadjuvant chemoradiation (Capecitabine + 5000 Gy) was carried out with pathological partial response. In November 2018 he underwent a Transanal Total Mesorectal Excision (TaTME) with permanent colostomy fashioned for uncertain residual of Denonvilliers fascia and prostatic plane. The pathology report showed a moderately differentiated invasive adenocarcinoma staged as ypT3, ypN0, Rx; Mandard tumor regression grade 3. Postoperative adjuvant Capecitabine chemotherapy was administered from December 2018 to April 2019. Close follow-up examinations showed a radiological complete regression until May 2020 when abdominal CT-scan demonstrated the presence of pelvic recurrence. Peritoneal disease progression was observed from June to September 2020, despite a first line chemotherapy (FOLFOX regimen) and a second line treatment (FOLFIRI regimen). PIPAC was first performed in November 2020 according to standard protocols. Two double-balloon airtight trocars were used: the first one for the camera connected to the CO2 insufflator, the second one, connected to a closed aerosol waste system (CAWS), for working instruments and the micropump nebulizer used for delivering chemotherapy under pressure. Laparoscopic evaluation of peritoneal metastasis extension according to the Sugarbaker Peritoneal Cancer Index (PCI) was performed: tumor nodules were observed on the greater omentum, in pelvis and on the diaphragmatic surface and the PCI-score calculated was 13. Ascitic fluid was drained and sample peritoneal biopsies were taken to assess Peritoneal Regression Grading Score. The pressurized aerosol containing Oxaliplatin at a dosage of 92 mg/m2 BSA diluted in saline solution was administered inside the peritoneal cavity for 5 min. Afterward, 30 min CO2 insufflation under laparoscopic guidance was kept for aerosolized chemotherapy diffusion. At the end, the toxic aerosol was safely removed via CAWS. Results: Total operative time was 40 min. Postoperative course was uneventful with patient discharged on postoperative day 3. Patient is scheduled for further 2 PIPAC procedures at 6 weeks intervals. Conclusions: PIPAC is safe and well tolerated, has been validated for palliative treatment of ascites in patients with peritoneal carcinosis not responding to standard chemotherapy. In the last years several ongoing trials are carried on assessing the effectiveness of PIPAC in boosting tumor regression in association with second or third line chemotherapy.

Aims: To determine how operative workflows, displayed on auxiliary screens during a computer simulated operation, are perceived as adjuncts to learning and if use affects performance or cognitive demands. Methods: Inclusion criteria included basic knowledge of laparoscopic cholecystectomy and relevant anatomy, demonstrated by successful completion of accredited e-learning modules (TouchSurgeryTM). Participants who had previously performed a laparoscopic cholecystectomy were excluded. Technical competency was standardised through completion of Lapmentor simulator basic skills modules (SimbionixTM). The workflow was prepared by expert surgeons, using GoSurgeryTM software (TouchSurgeryTM), and detailed operative instructions to perform a level-1 laparoscopic cholecystectomy (example Figs. 1 and 2). Participants performed three simulated laparoscopic cholecystectomies. They were randomly allocated to complete the procedure without (control group) or with the workflows (GoSurgery group), and then crossover twice to the opposite arm. After each simulation, participants completed a validated task load index for surgical procedures (SURG-TLX), measuring perceived cognitive demands. After the study, participants completed feedback questionnaires including Likert-style statements based upon Kirkpatrick’s training evaluation. Screen-recordings of simulated operations were blindly assessed by expert surgeons, using validated scores: Objective Structured Assessment of Technical Skill (OSATS) and laparoscopic cholecystectomy specific performance and error scores (Eubanks et al., 1999). Statistical significance was defined with a p-value < 0.05. Results: Forty-eight medical students, doctors and surgical trainees were recruited. Significant improvements were noted with repeat attempts for OSATS, Error scores and time taken (p < 0.01), but not for performance scores (p = 0.272). At the final attempt, the GoSurgery group performed marginally better than controls, with median OSATS (19 v. 17, p = 0.989), performance (72 v. 71.5, p = 0.730) and error scores (17 v. 22, p = 0.268) favouring the intervention group, although not significantly. Surg-TLX scores were reduced when using workflows but this only reached statistical significance for the Temporary-Demands domain (Mental-Demands p = 0.353, Task-Complexity p = 0.502, Situational-Stress p = 0.223, Distractions p = 0.126, Temporal-Demands p = 0.037). Procedure time was significantly longer in the GoSurgery group (20.5 v. 14 min, p = 0.033). More than 90% of participants agreed that workflows were enjoyable, user-friendly and aided learning. Conclusion: Real-time operative workflows are perceived as useful adjuncts to learning in simulated environments and may diminish cognitive burdens. Workflows improved operative performance scores and diminished errors, although not significantly. Further research is needed to determine effects at different training levels on a larger scale, with possible applications in formal surgical training programmes.

Aim: Show a 95% gastrectomy laparoscopic approach after a Billroth I procedure Methods: description of technique in video presentation Results: We show the 95% gastrectomy laparoscopic procedure in a patient who suffered a gastric adenocarcinoma in the anastomosis of a previous Billroth I gastrectomy COnclusions: 95% gastrectomy is a feasible procedure in selected cases

Background: The adrenal gland is an upper-abdomen organ, located at the posterior retroperitoneal space. Adrenalectomy with the traditional transabdominal laparoscopic (TTLA) technique may be challenging, in particular for the resection of large tumors. TTLA comprises the surgical mobilization of all the abdominal organs situated in front of the adrenal, with the addition of adhesiolysis in the case of previous transabdominal operations. On the contrary, the posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive technique that provides direct access to the retroperitoneum. In PRA the adrenal resection is achieved without any other-organ mobilization or adhesiolysis with a drawback of limited operative space. Concerning large unilateral adrenal masses (> 6 cm) where cancer is suspected open surgery is still an acceptable option according to the latest European Society of Endocrinology Clinical Practice Guideline. The rationale is that with increasing tumor size there is higher risk for tumor capsule rupture and recurrence if minimally invasive surgery is performed. Aim: We present a video of a right PRA for a 6.3 cm metastatic adrenal cancer with the novelty of left-handed dissection (LHD) on the crucial structures of the vena cava and the right adrenal vein. We aim to show that PRA and an intact surgical specimen are feasible even for large adrenal tumors (> 6 cm) and that sufficient working space is achieved with the use of LHD in a right-sided procedure. Procedure: The right PRA is performed in a patient with a large mass at the right adrenal with the suspicion of rectal cancer metastasis. In the past, the patient underwent low anterior resection of the rectum for cancer. As shown in picture 1, the patient is in prone position and 3 ports are used in the right back subcostal area with the camera in the middle port. The proximity of the left port (surgeon’s left hand) to the vena cava and to the adrenal vein is obvious. Instead, the adrenal mass is in the way between the right port (surgeon’s right hand) and the crucial veins, creating a challenge for a right-handed dissection on the structures medial to the adrenal. In our video, the dissection starts medially to the adrenal with the use of the (right-handed) surgeon’s left hand. The posterior surface of the vena cava is fully exposed and freed from any tissues, the adrenal hilum is freed intact, and the right adrenal vein is divided. LHD is continued to fully mobilize the adrenal. The intact surgical specimen is removed with an endo-basket. Conclusion: Left-handed dissection facilitates the crucial medial dissection in right-sided PRA for the resection of large adrenal mass. The use of LHD overcomes the challenge of limited operative space or of the bulging of the adrenal mass in right PRA. The advantages of minimally-invasive PRA should be considered also in patients with a large mass located in the adrenal.

Introduction: Sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures. However, the available literature on histological examination of the resected sleeved stomachs is widely inconsistent. This study aimed at assessing the histopathological findings after SG performed in our center compared to the routinely performed preoperative esophagogastroduodenoscopy (OGD) and the intraoperative findings. Methods: We conducted a retrospective cohort study using the bariatric unit database of all patients who had SG procedures from June 2007 to December 2019. Results: Out of the 620 SG performed, there were 219 patients with complete data, including preoperative OGD reports, operative notes, and postoperative histopathology reports. We found normal specimens in 43.83% (n = 96) and evidence of inflammation in 50.68% (n = 111) of cases. There were 10 (4.56%) specimens with evidence of inflammation and other lesions and two (0.91%) specimens with lesions only. Twenty-five patients had inflammation, and 10 had lesions on preoperative OGD with negative histopathology reports. Conclusion: Routine histopathology examination after SG does not change the management, and preoperative OGD can detect inflammatory changes and lesions, which could have been missed with histology analysis only (Tables 1 and 2 ). Figure 1 Table 1 Types of inflammation Table 2 Lesions detected on histoathology examination Types of inflammation Lesions detected on histoathology examination

Introduction: DPDS is one of the frequently overlooked complications of acute pancreatitis. That’s why it’s an open and actual problem. Currently, it is not fully known which is preferable: early surgical intervention or step up approach. Aims: To show an effective method for treating giant pancreatic head pseudocyst when minimal invasive approach is inefficient. Methods: Male born in 1984 with giant pancreatic head pseudocyst (PC). In anamnesis: some cases of acute pancreatitis with conservative treatment. Real exacerbation started with jaundice, growing up nausea and vomiting. On CECT there is a pancreatic head pseudocyst 100 × 155 mm which is heterogeneous due to septums and big soft tissue inclusion (26 cm3) without contrast enhancement. The PC compresses common bile duct, portal and inferior cava veins, violates the emptying of the stomach. In this case DPDS also include dilatation of the main pancreatic duct throughout and pancreatic tail PC (35 × 18 mm). In accordance with CECT data, high risk of rupture, percutaneous, transpapillary and transluminal drainage was associated with small success rate. A decision was made to create fully laparoscopic cystojejunostomy. Features of surgery: The PC had been partially mobilized, a puncture with urgent cytological examination of the cystic fluid was performed. No data of malignancy was received. Was performed manual intracorporeal one-layer end-to-side interrupted anastomosis between PC and Roux-en-Y loop using Prolene 2/0. Results: In early postoperative period all symptoms were resolved. The operation lasted 120 min, blood loss was 100 ml. The patient was discharged on the 12th day after surgery. Conclusion: laparoscopic cystojejunostomy is an effective minimal invasive and low traumatic technique. It can be used for treatment pancreatic PC and walled of necrosis (WON) when they contain septated fluid cavities with big soft tissue component.

Background: Emerging evidence from observational studies suggests that complete mesocolic excision (CME) during surgery for Crohn’s disease (CD) may reduce recurrence. However one of the reservations against routine use of CME is that in advanced CD mesentery is frequently inflamed thickened and bleeds heavily during transection. Hence conventional surgical resection is performed close to the bowel wall leaving the diseased mesentery in situ. We perform laparoscopic CME for patients with ileocolic CD. We however do not use energy source or en mass clipping for central vascular ligation. Instead, we secure the ileocolic artery and vein separately at their origin with dissection, individual ligation & division. With this technique, CME can be performed safely and in blood less field. A short video of our technique is presented. Brief description: A patient in his early twenties presented with history of recurrent pain abdomen and after extensive investigations was diagnosed to have ileocecal CD. His symptoms persisted on medical therapy and later he developed sub-acute intestinal obstruction (Fig. 1). After resolution of obstruction on conservative management he was offered laparoscopic ileocolic resection with CME. Initial diagnostic laparoscopy was performed and omental adhesions were taken down. Subsequent to dissection of ileocolic artery and vein separately, they were divided between the clips with scissors without using energy device (Fig. 2). Medial to lateral dissection of mesocolon and right colon from retroperitoneum was performed as in standard CME. After complete mobilization, extracorporeal stapled transection and hand-sewn two layered, side to side ileocolic anastomosis was fashioned. Thus en bloc removal of the diseased bowel segment along with intact fascial coverage of the disease and all blood vessels, lymphatics, lymph nodes and fibro-fatty tissue was performed. Conclusion: Laparoscopic complete mesocolic excision with separate ligation of ileocolic artery and vein at origin is a useful technique of safe mesentery resection for ileocolic Crohn’s disease.

Aims: Rectal cancer is a common disease. Sometimes its diagnosis is late. This situation increases the possibility of presenting complications such as tumor perforation. Early diagnosis and effective treatment of this complication is important; as it can lead to a serious infection and compromise the patient’s life. The objective is to present the treatment of a patient with an abscessed rectal neoplasm. Methods: The case of 69-year-old man is presented. He has a lower rectum adenocarcinoma and he is awaiting initiation of neoadjuvant treatment. He goes to the emergency room for intense anal pain and induration in the gluteal area. On examination, a tumor mass emerged through the anal canal. It also presents an erythematous and fluctuating region in the adjacent perianal area. In the analysis, the acute phase reactants are elevated. Therefore, it was decided to perform urgent surgery. Results: Surgical intervention is performed using laparoscopic approach through a single port. An incision is made in the left iliac fossa and a single port is placed over the incision. A lateral approach is performed and the sigmoid colon is released. A loop colostomy is removed and it is fixed with loose stitches. The perianal abscess is drained and debrided, and a Penrose drain is placed inside. The postoperative period is satisfactory. Conclusion: Performing a colostomy using a laparoscopic approach is very beneficial for the patient. And one option, it is performed through a single port. It allows a good assessment of the extent of the neoplasm. It also helps to appreciate the different possibilities of exteriorization of the intestinal loop. In addition, it avoids the performance of a wide and traumatic laparotomy with the psychological impact it implies for the patient.

Radiofrequency energy has been used both experimentally and clinically to manage the pancreatic remnant after distal pancreatectomies. Our goal was to determine whether endoluminal radiofrequency (RF) ablation of the main pancreatic duct in large animals would be more efficient than glue occlusion as an exocrine pancreatic atrophy-inducing procedure. Thirty-four Landrace pigs were assigned to either the transpapilar (n = 16) or transection (n = 18) groups. The transection implied the pancreas neck was severed. In each of these groups the remaining distal pancreatic duct was occluded either by RF or by glue. In the transpapilar group complete atrophy was observed in all the RF cases, while atrophy was incomplete in all the members of the glue subgroup. The failure rate of the main pancreatic duct (usually expressed by a pseudocyst) in the transection groups was dramatically higher in the glue subgroup than the RF subgroups (9 out of 9 and 1 out of 9, respectively) and postoperative mortality occurred only in the glue subgroup (3 out of 9). These results show the superiority of endoluminal RF ablation over glue for main pancreatic duct occlusion, as seen by the degree of atrophy and fewer postoperative pancreatic fistulas.

Aims: To examine the experience of a patient with gallbladder agenesis and acute cholecystitis like-symptoms, incidentally diagnosed during laparoscopic cholecystectomy. Methods: We retrospectively evaluated our first case of surgically confirmed gallbladder agenesis after 753 consecutive cholecystectomies performed from September 2016 to March 2021 in the Surgical Unit of “Renzetti” Hospital in Lanciano, Italy. Results: The incidence of gallbladder agenesis was around 0.13% in our series. A fragile 84-year-old patient presented dyspepsia and vomiting with acute pain in the right upper quadrant of the abdomen. Ultrasound imaging supported the diagnosis of acute calculous cholecystitis with chronic inflammation, atrophy and sclerosis. Laboratory tests showed acute inflammation with increased white blood cell count (15,43 × 10^3/uL) and total serum bilirubin level of 1,81 mg/dL. The indexes of cholestasis and serum tumor markers (CEA, CA 19–9, α-FP) were normal. During laparoscopy, we found a proximal transverse colonic angle strictly adherent to the gallbladder fossa. None well-formed gallbladder with classic pear shape was observed. After mobilization of the colon, we observed the presence of a small dysmorphic cyst of 2 × 2 cm, along the bed of the gallbladder. The surgical procedure was concluded after lysis of colonic-hepatic adhesions and repair of small areas of colonic peritoneal lacerations with absorbable sutures. The post-operative period was uneventful. The CT (computed tomography) scan of the abdomen and the magnetic resonance cholangiopancreatography (MRCP) eventually confirmed the diagnosis of lithiasic gallbladder agenesis. The patient was discharged in good clinical conditions and scheduled in an observational radiological program. Conclusions: Gallbladder agenesis is a rare embryological anomaly, often asymptomatic, but frequently mimicking acute cholecystitis syndrome. Especially during the last decade, gallbladder agenesis is commonly diagnosed after minimally invasive surgery. Surgeons have to be familiar with this rare entity and any conversion in laparotomy or unplanned surgical strategies should be indicated in the same operative setting.

Aims: Benign multicystic peritoneal mesothelioma (BMPM) is a very rare disease with an annual incidence of 1,5–2 in 1,000,000. It usually occurs in reproductive age women and may be associated with endometriosis, pelvic inflammatory disease and previous surgery. A urachal cyst occurs when the foetal urachus fails to obliterate completely. Urachus abnormalities are rare in adults and urachal cysts usually manifest when infected. Methods: A 35-year-old female presented to the consultation clinic with right iliac region pain lasting for about 1 year. Previous gynaecological examination found no ovary pathology and the patient had no previous surgery. Abdominal ultrasound showed a local fluid collection medial to the ascending colon indicating a cyst and suspicion of an urachal cyst. CT showed a collection of clear fluid intraperitoneally along the right lateroconal fascia bellow the liver—most likely a peritoneal cyst, and a cystic mass anterior to the urinary bladder – most likely a urachal cyst. Both cysts were resected laparoscopically and sent for pathological examination. Intraoperatively, the peritoneal cyst was located on the right parietal peritoneum. Pathology reported a BMPM (alternatively, “multilocular peritoneal inclusion cyst “) and confirmed a urachal cyst. The patient was discharged with no complications and a recommendation for future follow-up. Results: Owing to the rarity of BMPM, with only around 200 cases reported world-wide, many surgeons might not recognize the possibility of recurrence or malignant transformation. Most BMPMs are incidental findings and usually arise from the pelvic peritoneum. In this case, the patient experienced pain and the mass was located on the anterior abdominal wall, which is atypical. Malignant peritoneal mesotheliomas are much more common, so any peritoneal mass should be examined for malignancy. The definite diagnosis is made solely based on histology. Treatment of BMPM ranges from observation to complete surgical resection or, in cases with incomplete resection and a high chance of local recurrence, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. As for treating urachal cysts, complete excision is recommended due to risk of malignancy. As most urachal cysts manifest with infection, a two-stage approach (incision and drainage followed by secondary excision) leads to less complications. In this case, the urachal cyst was found incidentally, and a single-stage excision yielded excellent results. Conclusions: We present a case of a female patient with a BMPM and a urachal cyst – two rare pathologies. With complete surgical resection chances of BMPM recurrence are low and with follow-up should be caught promptly.

Introduction: Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric procedures around the world. Omentopexy is a novel technique performed during LSG. There is no clear conclusions of indications for this procedure, safetyness and effects of such a method. Aim: To compare the outcomes of laparoscopic sleeve gastrectomy (LSG) with omentopexy (OP) and without omentopexy. Methods: We searched the Medline, EMBASE, and Scopus databases in June 2020. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines. Results: From 66 articles, 4 studies (N = 1396 patients) were included in the meta-analysis. One randomized trial. Our findings showed that LSG with omentopexy had significantly lowered overall morbidity compared to LSG without omentopexy (MD = 0.38; 95% CI [0.15, 0.94]; P = 0.04) (Fig. 1). Gastric leakage rate (MD = 0.17; 95% CI [0.04, 0.76]; p = 0.02) was also significantly lower in group of LSG with omentopexy (Fig. 2). In length of stay, there were no significant differences between groups. Conclusions: Our meta-analysis showed that LSG with omentopexy can be a feasible procedure for decreasing morbidity and gastric leaks rate. However, despite promising results, still lack of well quality studies. There is substantial need for more studies, mainly for large randomized controlled studies.

Introduction: This video presents the case of a 61-year-old man that underwent Roux-en-Y gastric bypass who 6 years later was diagnosed of a gastro-gastric ulcer upon a marginal ulcer on the gastro-enteric anastomosis. The aim is to describe the technical steps to resect an anastomotic ulcer and convert the gastro-gastric fistula to a novel gastric bypass using robotic surgery. Case description: This video presents the case of a 61-year-old man that underwent Roux-en-Y gastric bypass (RYGB) in 2013 due to a BMI 47.23 kg/m2. Five years after bariatric surgery, the patient started to complaint of epigastric pain, vomiting and difagia, reason why a gastroscopy was performed, which found a marginal ulcer on the posterior wall of the gastro-enteric anastomosis, classified as Forrest III, which was treated conservatively. A year later, due to persistence of the previously described symptoms and weight regain, a barium swallow tests and a second gastroscopy were conducted, which revealed a large gastro-gastric fistula between the gastric pouch and gastric remannent, with no other fistulas nor strictures. Robotic surgery was proposed in order to give a definite treatment. Intraoperatively, first the the gastro-jejunal anastomosis was dissected in order to see the perforated ulcus on its posterior surface, which fistulized towards the gastric remnant. Disconnection of the anastomosis was performed. Hiatal hernia was opened to be able to close the diaphramic pillars with 3 ethibond points. Excision of the distal part of the gastric pouch was conducted, as well as the pouch’s resyzing with robotic green stapler and vertical section reinforcement with PDS. Reanastomosis of gastro-yeyunostomy was carried out with a blue robotic stapler and closure reinforcement with a manual double plane of vycril and PDS. Furthermore, a Candy Cane resection was performed with a blue stapler. The Petersen’s defect was reclosed with Ethibond. Furthermore, the fistulous orifice in the gastric remnant was closed with continuous vicryl suture. Finally, exluded parts were extracted, hemostasia controlled, and with methylene blue the absence of leaks in the gastroyeyunal anastomosis was verified. The patient had a favourable immediate postoperative period and was discharged 48 h after surgery. Discussion: Although gastro-gastric fistula after RYGB is a rare complication, it is important for the bariatric surgeon to be able to recognize its signs and symtomps in order to offer a prompt and accurate treatment. Robotic technology has proven to be succesfull in its surgical management demonstrating good surgical outcomes.

Appendicular mucocele is an uncommon pathology of the appendix. It is defined as an aseptic distension of the appendicular lumen with mucous secondary to blockage of the outflow into the caecum due to fibrosis, mucosal hyperplasia, mucinous cystadenoma, or cystadenocarcinoma. Due to a lack of specific symptoms, pre-operative diagnosis of an appendicular mucocele may be challenging. Radiological investigations may not be able to provide an accurate diagnosis as the findings are similar to features of right adnexal cystic lesion. Although colonoscopy may be normal, it can show extrinsic pressure on the caecal wall,—“volcano sign” is a typical colonoscopy feature which demonstrates the appendicular orifice surrounded by a firm mound covered by normal mucosa. The gold standard treatment of a benign mucocele is surgical excision. Though a laparoscopic approach is widely used for colonic resections and acute appendicitis,, the safety and efficacy of laparoscopic resection of an appendicular mucocele is controversial and not globally accepted due to the risk of perforation and subsequent pseudomyxoma peritonei. Pseudomyxoma peritonei is a known complication of ruptured mucocele caused by spillage and implantation of mucin-secreting cells within the peritoneal cavity. Therefore, minimal-manipulation technique should be utilised to minimise the risk of rupture and complication rate of pseudomyxoma peritonei during a laparoscopic procedure. This can be achieved by transecting the base of the caecum by using endoscopic stapling devices and using a laparoscopic bag to safely contain the specimen and minimise the risk of specimen rupture. Care should also be taken to ensure that the ileo-caecal junction is well away from the staple line and is not narrowed or tented during the procedure. In our video, we present a case of appendicular mucocele with pre-operative radiological and colonoscopy findings and demonstrate a safe performance of excision of appendicular mucocele using a laparoscopic stapler to transect the base of the caecum keeping well away from the ileo-caecal junction. The procedure is performed as a day case and we believe it to be the preferred option to open surgery.

A great part of the population worldwide underwent or will benefit from a GBP. It is estimated that up to 30% of those people will report chronic abdominal pain. The main difficulty is to compare some symptoms to the general population and assess what is allegedly directly related to Gastric Bypass Surgery. We reviewed all the literature from the last 20 years and collected the few data available. Visceral pain has some particular patterns of presentation way different from pain in other locations of the body. Among the great chapters regarding pain following GBP surgery are those related to stenosis, reflux, ulcers, internal hernias and adhesions. They are well known and not addressed in this talk for time considerations. Among the many other potential causes of abdominal pains we'll focus on some less known, sometimes discussable entities but of major concern in some cases, all potentially related to Gastric Bypass. Our meticulous work led us to the conclusions that after Gastric Bypass Surgery and Bariatric Surgery in general, a lot of abdominal different pains can occur. It is often difficult to establish a direct link between the procedure and the symptoms. A lot of diagnostic methods exist, the anatomical modifications due to GBP surgery make some -like endoscopies- more difficult to perform. Laparoscopy can be an important diagnostic and management approach, sometimes the only diagnostic procedure. We should warn our patients about those tedious potential situations and surgeons should report all those situations.

Introduction:-Single Anastomosis Sleeve Ileal Bypass(SASI)is a Novel Metabolic/Bariatric Surgery operation based on Santoro’s bipartition operation.It can be offered for patients with weight regain after Sleeve gastrectomy. Sleeve gastrectomy (SG)is a commonly performed bariatric procedure.Weight regain following SG is a significant issue.Yet,the understanding of this phenomenon is still unclear.Rates of regain ranged from 5.7% at 2 years to 75.6% at 6 years.SASI bypass was an option for some candidates having SG done 2 years back and failed to achieve the required weight loss or having weight regain.In SASI bypass,Resleeve gastrectomy of the dilated gastric pouch is done followed plication of the stapler line then creating a Bipartition channel doing a side to side gastro-ileal anastomosis. Aim : The aim of this study is to report the clinical results and the outcomes of SASI bypass as a therapeutic option for patients with weight regain after SG. Methods: We conducted a retrospective study for 75 morbidly obese patients having history of SG done more than 2 years back and failed to achieve and/or to maintain the required BMI. Exclusion criteria : Patients with history of Bypass Bariatric Surgery and patients with documented psychological instability or intolerability for regular follow up. Procedure was done at Sidra Hospital in kuwait from February 2017 to November 2019. Using 5 ports,Resleeve Gastrectomy was performed over36 fr bougie tube starting 6 cm above the pylorus then gastro-ileal anastomosis (side to side)was performed 6 cm above the pyloric ring to an ileal loop counted 300 cm from the ileocaecal valve. Data was collected from the patients including:Weight loss progress,laboratory full results. Discussion and Results: During the study period:75 morbidly obese patients with a mean BMI of 44 ± 6 kg/m2 were evaluated.-%EWL(excess weight loss)reached 64% at two years-Diabetes was cured in the known diabetic patients (type2)within 6 months. Follow up laboratory results were normal in 88% of patients (all were kept on regular vitamins and proteins supplementation for 2 years). 3 patients had hiatal hernia that was repaired during the procedure and 2 patients had asymptomatic gall stones that was discovered during the routine preoperative work up for whom Laparoscopic cholecystectomy was done at same cession before starting the SASI procedure. Conclusion: SASI Bypass is a promising operation that offers a good weight loss for morbidly obese patients having weight regain after SG. Figure 1

Endoscopic TAPP and TEP inguinal hernia repair are performed according to the principles of conventional Stoppa's operation, which was introduced by R. Stoppa in 1973. This operation reduced the recurrence rate of inguinal hernias to 1.4%. Patient B., 70-years-old was admitted to Lviv Regional Clinical Hospital with bilateral reducible inguinal hernia (right sided – M2, left sided hernia – M3). No concomitant cardiorespiratory diseases. The patient was performed bilateral laparoscopic TAPP plastics with the use of one large mesh 24 × 13 cm. The mesh was fixed with vicryl to posterior surface of rectus abdominis muscles. Parietal peritoneum was sutured above the mesh with absorbable V-lock suture. No complications in the postoperative period. On 11 month follow-up no recurrence. Conclusions. The use of laparoscopic technologies has allowed, in addition to a low recurrence rate, to significantly improve the comfort of the postoperative period, due to a lower percentage of chronic pain and a good cosmetic effect.

Aims: Show how technical difficulties when performing certain surgical gestures with the robotic platform are reduced during the umbilical hernia repair. Methods: A 35 years-old woman with a medical history of hypothyroidism, and without prior surgical procedures. Reffered to the consultation for discomfort associated with primary umbilical hernia, without incarceration crisis. On examination, the patient presented a primary umbilical hernia of diameter 2 cm, which associated large rectus abdominis diastasis. TARUP was proposed, which the patient accepted with prior informed consent. Results: The procedure was carried out entirely with a robotic platform. The surgical time was a total of 240 min. The use of robot-assisted minimally invasive surgery improved the efficiency of the dissection phase, suture and the ergonomics for the surgeon. The mesh was placed in a retromuscular position. There were no intra- or postoperative complications and the patient was discharged after 48 h. Conclusion: TARUP technique is reproductible and safe. It avoids the placement of an intraperitoneal mesh, reduces wound complications and the postoperative pain. In addition, the robotic approach allows suturing with more precision and comfort in comparison to conventional laparoscopy. It is probable that in the next years, with an increased availability of robotic platforms and with more surgeons trained and experienced in their utilization, a greater number of hernia repairs will be made using a minimally invasive approach assisted by robot.

Aims: Morgagni hernia is a rare congenital defect usually diagnosed and treated during adulthood. To date, there is no consensus on its treatment. The surgical repair can be performed with thoracic or abdominal approach. If compared with the thoracic approach, laparoscopy has several advantages as an easier reduction of the hernia, the possibility to inspect the whole diaphragm to identify other defects and to evaluate, and possibly treat, the abdominal content of the hernia. This video shows our technique to perform a laparoscopic repair of an anterior diaphragmatic hernia with mesh insertion. Methods: The patient is placed in supine split-leg position and three trocars are used. We begin with our technique for transversus abdominis plane and retrorectal blocks for pain control. Following, after the reduction of the greater omentum, the hernia sac, with the preperitoneal fat, is completely dissected from the thoracic structures and from the diaphragmatic muscles. The complete mobilization of the sac from the muscles allows a tension free closure of the defect. The defect is closed through a non-resorbable barbed running suture. A 12 cm PVDF mesh is placed on the muscular layer and fixed to the diaphragm and to the abdominal wall with non-absorbable anchors. The peritoneal flap and the mesh are fixed together to the abdominal wall. Results: The postoperative course was uneventful and the patient was discharged on postoperative day 2. Conclusions: Laparoscopic transabdominal preperitoneal repair for treatment of Morgagni hernia is safe and associated with several advantages, like diaphragm inspection and evaluation of hernia content.

Background: Laparotomy / thoracotomy has been the traditional approach to traumatic diaphragmatic and splenic injuries, especially in unstable patients. Open repair of diaphragmatic defects can however be challenging due to difficulty in exposure especially in posterior defects. Laparoscopic approach provides optimal view of the surgical field and potentially reduced post-operative recovery time and length of stay. The aim of the case is to demonstrate the laparoscopic technique in the context of code-red trauma including peri-operative, and technical considerations. Method: A 29-year-old male motorcyclist who was hit by a car and stabbed in the left posterior chest and flank in an attempted robbery, sustained an open book pelvic fracture, massive left tensioning haemothorax, large diaphragmatic and splenic injury. Emergency laparoscopy was carried out in conjunction with intensive resuscitation and stabilisation in a multidisciplinary approach. Firstly, the patient was put in a reverse Trendelenburg position adjusted for respiratory and hemodynamic stability; split-legged position was not feasible due to pelvic fractures. With adequate exposure, herniation of left liver lobe, shattered spleen, stomach and omentum through the 15 cm posterior diaphragmatic tear was reduced. Active bleeding from the splenic artery was identified and oversewn with 2/0 PDS; shattered segments of spleen was resected, preserving 60%. Finally, diaphragmatic defect was closed with continuous 1 Ethibond suture. Results: The patient was managed in the intensive care unit post-operatively. Repeated Computerised Tomography scan on post-op day 5 showed an intact diaphragmatic repair, resolving haematoma of the residual spleen and no evidence of undetected intra-abdominal injuries. Clinical care was taken over by Orthopaedic team to manage bony and soft tissue injuries. Conclusion: Laparoscopy remains an advantageous approach in the acute repair of traumatic diaphragmatic injury with careful patient selection and intraoperative planning. There are few cases reported in the literature. Patient position and surgical field exposure may be restricted in the presence of polytrauma. Multidisciplinary collaboration including trauma anaesthetists and experienced laparoscopic surgeons is paramount to the success.