Abstracts of Presentations Made at MINIMALLY INVASIVE SURGERY WEEK 2024 September 25–28, 2024 Lake Buena Vista, Florida, USAGENERAL SURGERY SCIENTIFIC PAPERS & VIDEOS

Objective: At most centers, patients with sigmoid diverticulitis, who are candidates for elective surgery undergo conventional laparoscopic/robotic extracorporeal-assisted surgery. The NICE procedure is a completely intracorporeal anastomosis with extraction of the specimen through the rectum. Here we present 3 successful cases of robotic NICE procedures for complicated diverticulitis, completed at our rural community hospital, which has implications for improved outcomes. Methods and Procedures: Consecutive patients presenting with complicated diverticulitis, ie, fistula, abscess, stricture—undergoing the NICE procedure in April 2024 were evaluated. Intraoperative and postoperative data were collected and reviewed. The data extracted included demographic, clinical data, disease features, and outcomes data. The main outcomes assessed were operative time, time to return of bowel function, pain scales, and length of stay. Results: Three patients underwent the NICE procedure electively for complicated recurrent diverticulitis. All cases required intricate dissection due to the complexity of their diseases and had successful intracorporeal anastomosis and extraction of specimen through the rectum. None experienced postoperative leaks or infections. The mean operative time was 365 minutes. Average time to bowel movement was 4.7 days. Average pain scales were less than 4 by postoperative day 4. Finally, the mean total length of stay was 5.6 days. Conclusion: We hypothesize the robotic NICE procedure is a successful alternative to traditional diverticulitis surgery, without a negative effect on complication rates and better patient outcomes at our rural community hospital. Our greatest limitation is sample size; however, after these successful cases we anticipate many more to come.

Objective: The aim of this study was to conduct a systematic review and meta-analysis to evaluate the influence of previous prostatectomy in men undergoing minimally invasive surgery (MIS) inguinal hernia repair (IHR). Methods and Procedures: We searched Cochrane Central, Scopus, SciELO, Lilacs, and PubMed/MEDLINE for studies comparing men undergoing MIS IHR after prostatectomy with men without previous pelvic surgery. Outcomes evaluated included recurrence, overall postoperative complications, seroma, hematoma, surgical site infection (SSI), conversion rates, and operative time (OT). Results: 9 studies met the inclusion criteria. Three analyzed totally extraperitoneal (TEP) technique, while 4 analyzed transabdominal preperitoneal (TAPP) and 2 presented both techniques together. The analysis comprised 189,183 patients, of which 4,551 (2.4%) had a history of prostatectomy. Postprostatectomy patients presented higher postoperative complications (3.7% vs 1.9%; RR 1.9; 95% CI [1.23; 2.94]; P  = .004) and seroma (1.6% vs 0.9%; RR 1.58; 95% CI [1.23; 2.04]; P  < .001) following MIS IHR. Patients with a previous prostatectomy presented an increased OT (MD 21.25 minutes; 95% CI [19.1; 23.4]; P  < .001). No differences were observed in recurrence (0.98% vs 0.92%; RR 1.1; 95% CI [0.8; 1.53]; P  = .54), SSI (0.07% vs 0.07%; RR 0.99; 95% CI [0.34; 2.9]; P  = .98), hematoma (3.6% vs 1.2%; RR 3.18; 95% CI [0.84; 12.1]; P  = .09), and conversion rates (1.1% vs 0.9%; RR 1.26; 95% CI [0.91; 1.72]; P  = .16). Conclusion: This study indicates that patients with a history of prostatectomy undergoing MIS IHR may present higher postoperative complications and an increased operative time.

Objective: Minimally invasive procedures for benign prostatic hyperplasia (BPH) have emerged to preserve sexual function, including those with metallic devices. However, aging patients requiring MRIs for prostate cancer screening may experience significant image distortions due to these clips, especially at higher magnetic field strengths. This study evaluates the impact of BPH procedure metallic artifacts on image quality and interpretation in 3 Tesla (3T) and 1.5 Tesla (1.5T) MRIs. Methods and Procedures: Data were gathered from patients with hip prostheses, BPH procedure clips, or both, who underwent 3T or 1.5T MRIs. Evaluation criteria included spatial misregistration, signal void, geometric distortions, and thermal mapping distortion. MRI interpretations were conducted by a radiologist and urologist, assigning a Prostate Imaging Quality Score (PI-QUAL) on a 1–5 scale. Results: The 1.5T MRI demonstrated reduced signal voids, geometric distortions, thermal map distortion, and spatial misregistration compared to the 3T MRI, which showed significant signal voids in the anterior prostate. However, PI-QUAL scores between 3T and 1.5T were not statistically different ( P  > .1). Despite improvements at 1.5T, clip-induced signal voids in the anterior prostate remain problematic for detecting clinically significant prostate cancer. Conclusion: MRI distortion was significant at 3T compared to 1.5T, with BPH procedure clips causing substantial signal voids in the anterior prostate, complicating cancer detection. Patients with BPH procedure implants should consider a transperineal approach and be informed about these metallic artifacts’ effects on MRIs of the prostate, particularly when continuing PSA screening through MRI-guided biopsies.

Objective: Endometriosis is a chronic inflammatory syndrome that is the most common cause of chronic pelvic pain in women. Endometriosis of the appendix is less common but it can present as acute appendicitis, appendiceal invagination, atypical abdominal symptoms or be asymptomatic. Here we present a small case series dedicated to encounters of endometriosis with appendiceal involvement during laparoscopy, and analysis of prevalence and management. Methods and Procedures: This was a retrospective case series between the years 2018 and 2024. The patient cohort comprised 28 patients, age range 19–66 (mean age of 37), with a history of chronic pelvic pain that underwent diagnostic laparoscopic surgery with appendectomy for endometriosis. Inclusion criteria was chronic pelvic pain and exclusion criteria was pregnancy, suspected infectious etiology as cause of pelvic pain and prior history of hysterectomy. Results: Out of the 28 patients, 8 patients specifically complained of right lower quadrant abdominal pain (28%); 11 patients had pathology-confirmed endometriosis, with 2 having appendiceal pathology-confirmed endometriosis. Of the subgroup with complaints of right lower quadrant pain, 3 had endometriosis, 1 had acute appendicitis, and none had appendiceal endometriosis. The prevalence of endometriosis in patients with chronic pelvic pain, RLQ pain, and appendiceal endometriosis in this study were: 39%, 38%, and 18%, respectively. Conclusion: Although this study consists of a small sample size, it highlights associations of location of pain with appendiceal endometriosis. It also supports inspecting the appendix for gynecological disease during surgical management of chronic pelvic pain in women of reproductive age. ★ Gustavo Stringel Award for Best Poster by a Resident

Objective: Laparoscopic hysterectomy is a common gynecologic surgical procedure, and the single-port approach has become increasingly adopted. However, there is a lack of data regarding performing this procedure on large uteri, especially in the United States. This study aims to demonstrate the single-port approach for laparoscopic hysterectomies of large uteri. Methods and Procedures: This case series demonstrates 3 benign single-port hysterectomies performed on large uteri by a single surgeon from April 2017 to December 2023. Results: All 3 cases involving uteri weighing 1,500–3,050 g were successfully performed using a single umbilical port and the extracorporeal C-incision tissue extraction technique. There were no complications. Conclusion: Single-port hysterectomies on large uteri can be done safely and can be considered.

Objective: Artificial intelligence (AI) innovations are leaving a notable imprint in the medical field. In 2024, surgical subspecialties continue to experience the highest burnout rates, necessitating solutions to improve working conditions for surgeons. This paper aims to explore the potential applications of AI in reducing burnout, specifically within minimally invasive surgery (MIS). By examining the integration of AI tools and systems, we seek to identify how various technologies may streamline surgical workflows, enhance decision-making, and alleviate administrative burdens. Methods and Procedures: A comprehensive literature review was conducted, focusing on studies that have implemented AI in MIS. A list of relevant AI tools and systems was complied. Results: Current technologies include AI-driven intraoperative guidance to enhance precision during robotic surgery, 3D modeling systems for operative planning and navigation, and data analytics programs that offer predictive insights and procedural trends. Additionally, natural language processing and administrative tools streamline documentation, and intelligent monitoring systems assess patients’ vital signs. Conclusion: Various AI tools are designed to streamline surgery. Integrating AI in MIS not only strives to improve patient outcomes, but may also offer the additional benefit of combating surgeon burnout. Enabling surgeons to better assess risks, visualize anatomy and areas of concern, and implement measures that improve patient outcomes, minimizes physical exhaustion and ultimately surgeon stress. Continued research and development of AI, tailored to the needs of surgeons, are essential to fully realize their benefits and ensure successful implementation in the clinical setting. While preliminary findings are promising, further advancements are warranted to alleviate the inherent stress within MIS.

Introduction: Heavy menstrual bleeding affects ∼40% of reproductive aged women and is often treated utilizing uterine ablation (UA). Pain management protocols vary for in-office UA and there is no published pain management protocol specific water vapor UA. The study purpose was to evaluate pain management methods utilized by physicians following the conduction of in-office water vapor UA. Methods: An IRB-approved Qualtrics survey was completed by 32 physicians following an in-office water vapor ablation procedure. Results: The endometrium was pretreated in 59% of patients using progesterone and 68% received 10 mg progesterone and the most common length of treatment was 10 days. Misoprostol was given to 41% of patients. Acetaminophen was given to 41% of patients, the most common dose was 650 mg. NSAIDs were taken by 97% of patients, with 61% receiving ibuprofen 800 mg and 45% receiving ketorolac 60 mg IM. Narcotics were given to 81% of patients, with 35% receiving oxycodone/acetaminophen 5/325 mg. Anxiolytics were given to 63% of patients, with the most common being diazepam 10 mg 1–2 hours (55%) prior to UA. All patients received a paracervical block, and of those patients 56% received lidocaine 1%, and 9% percent received lidocaine 1% with epinephrine. Postablation, ibuprofen was given as needed in 75% of patients. Physicians perceived the procedure to be tolerated by patients in 94%of cases. Conclusion/Implications: Pain management strategies varied by physician but demonstrated patient tolerance of in-office water vapor UA. Further evaluation with a larger sample size is recommended.

Objective: To evaluate the effectiveness of indocyanine green (ICG) in delineating ureters during complex pelvic surgeries, especially in cases with extensive adhesions due to conditions such as endometriosis, repeat surgeries, and adhesions due to previous septicaemia. Methods and Procedures: In patients suspected of severe pelvic adhesions based on history, pelvic examination, and transvaginal ultrasound, we employed ICG to highlight the ureters. One vial of ICG was reconstituted with 10 ml of distilled water. During cystoscopy, ureteral catheters were inserted, and 2 ml of ICG was injected. The surgical procedure commenced, and the ureters were visualized due to their fluorescent appearance in overlay mode. Near-infrared (NIR) imaging was also utilized, which effectively highlighted the hydro-ureter. The fluorescence of the ureters appeared immediately post-ICG injection without any waiting time. Results: ICG was found to be safe, with no idiosyncratic reactions and no renal, or hepatic toxicity. Over 7 years and approximately 400 cases, the laparoscopic delineation of ureters using a 2 ml dosage of ICG was consistently effective. In the most recent 50 cases, we reduced the dosage to 1 ml without any loss of fluorescence. The overall fistula rate was minimal, with only one case reported of post hysterectomy fistula and in that case there was a malfunction in the camera system fluorescence mode. Conclusion: The use of ICG in complex adhesiolysis significantly enhances the safety and ease of the procedure for surgeons by clearly delineating the ureters, thereby mitigating the risk of inadvertent injury. The ureters show up themselves the surgeons do not have look for them. ★ Harrith M. Hasson Award for Best Presentation Promoting Education or Training

Objective: Esophageal cancer typically presents at an advanced stage with resultant poor survival rates. The yield of oesophago-gastro-duodenoscopy (OGD) undertaken on the 2-week wait pathway in diagnosing esophageal cancer is thought to be 5%. The 2022 esophago-gastric (OG) audit suggests only 35.9% of patients diagnosed with OG cancer were treated with curative intent. Raman spectroscopy of plasma and serum is a noninvasive and rapid diagnostic technique which has proved promising in cancer diagnostics. We aim to demonstrate whether this technique can accurately diagnose esophageal cancer (OAC). Methods and Procedures: Chemometric analysis of the spectral data from a proof of concept study undertaken by our team revealed Raman spectroscopy of plasma and serum to be 95% sensitive and specific in diagnosing OAC. Our research group has conducted a further study to validate these findings by reanalysing 60 of the samples from the proof of concept study in a separate lab. Results: Spectral peaks representing methylene deformation and C-O stretch of ribose were identified as discriminant spectral peaks in identifying OAC in both analyses, inferring that these results are reproducible. Specificity and sensitivity of 72% and 71% respectively was calculated from chemometric spectral analysis. Conclusion: We conclude that Raman spectroscopy has potential applications as a noninvasive screening tool for patients with suspected OAC in primary care.

Objective: To investigate a differential for a large abdominal cyst and to discuss multidisciplinary collaboration in minimally invasive surgery. Methods and Procedures: In a health professional shortage area of West Texas, a 59-year-old G7P5025 presented with acute on chronic epigastric pain accompanied by nausea, anorexia, and constipation. A well demarcated, 14.5–14.9 cm simple cyst arising from the left adnexa or flank was evident, although its distinct origin was unclear despite the robust employment of imaging studies—CT scan of the abdomen and pelvis with and without contrast, transabdominal ultrasound, transvaginal ultrasound, and MRI. The gynecological-oncology team, in accordance with the patient’s goals, proceeded with surgical management. Results: Pathology revealed a serous cyst with no evidence of malignancy, arising from the mesentery. Conclusion: When consulted for a pelvic mass, surgeons operating in the abdomen and pelvis are prudent to consider mesenteric cyst on their differential. Alongside the primary medical team, the consulting teams of general surgery, gynecology, urology, and gynecology-oncology all contributed to the collaborative care of the patient. Robotic-assisted laparoscopic surgery ultimately provided significant relief to the patient.

Objectives: Epigastric hernias, though less common than inguinal hernias, pose significant challenges due to their small size and incarceration of preperitoneal fat. The laparoscopic approach to epigastric hernia repair offers several advantages, including reduced postoperative pain, faster recovery, and improved visualization of the hernia defect. This video submission aims to demonstrate a standardized laparoscopic technique for the repair of epigastric hernias, highlighting key steps and technical nuances to optimize surgical outcomes. Methods: A 39-year-old male with no known comorbidities, past tobacco smoker and past surgical history of ORIF for distal radius fracture and treated H. pylori chronic gastritis presented with chief concern of 3-month history of pain and swelling over the epigastric region. Examination revealed 2 × 2 cm tender, reducible swelling over the epigastric region. CT scan showed fat containing ventral wall hernia situated 5 cm inferior to xiphoid bone and 8 cm superior to umbilicus. A small fat containing umbilical hernia was also noted. Results: The patient underwent laparoscopic epigastric hernia repair with mesh. Intraoperatively, 1-cm epigastric defect was noted with preperitoneal fat as the content. Reduction of contents was achieved followed by primary repair and preperitoneal polypropylene mesh placement. Conclusion: This video submission underscores the efficacy and safety of the laparoscopic approach, advocating its adoption as a preferred technique for epigastric hernia repair in suitable candidates.

Abaijan Sydney, 11 Abdalla Eshak, 7 Abdelnaby Abier, 10 Abdelnaby Abier A., 9, 11 Adetyan Hasmik, 17 Ahmad Khaleel, 18 Ahmad Saqib, 18 Ahmed Saad, 8 Al Harakeh Hasan, 3-4, 6 Alhashmi Fatima, 26 Al Marzouqi Omar, 13 Alao Hawwa, 4 Aldohayan Abdullah, 12-13 Aldohayan Abdullah Dohayan, 12 Allawi Ahmed, 15 Almasri Majd, 23 Alqasimi Hessa, 13 Alta Enrilen, 29 Amadi Sidney Moses, 23 Amodu Leo I., 15 Anoosh Farhad, 1 Atla Pradeep, 4 Baldonado Jobelle Joyce-Ann R., 31 Baldonado Jobelle J., 31 Ball Elizabeth, 21 Balthazar da Silveira Carlos A., 14 Barker Margot, 24 Barral Ann, 30 Beman Scott, 14 Bennett Robert, 16 Bhattacharyya Eesha, 20 Biebel Mark, 27 Bilik Alona, 1-2 Bird Victoria, 32 Bonatti Hugo J.R., 3, 32 Bonatti Hugo J.R., 2 Bowers Steven P., 28 Brathwaite Collin Em, 15 Burns Megan, 21 Burns Megan K., 20-21 Butler Kevin, 31 Caceres Miguel A., 22 Camacho Diego, 8 Cammock Hiley D., 14 Canton Silvio Alen A., 1 Cetin Esra, 18 Chapyala Shreya, 31 Cheng Connie, 24-25 Cherouveim Panagiotis, 18 Chitibomma Nikhilesh, 17 Christodoulou Maria, 3-4, 9 Clement Cecilia, 20 Colvin Juliana L., 7 Cordeiro Raquel N., 8 Cornejo Jorge A., 28 Couch Sarah E., 14 Covillo Kristana Milivojev, 4 Curcio Gary, 7 Czyszczon Katherine, 23 da Silveira Carlos A. Balthazar, 8-9 da Silveira Carlos B., 10-11 Dabrowski Gabrielle, 11 Dabrowski Gabrielle K., 28 Dahdaleh Fadi, 27 Daté Ravindra S., 9-10 De Abate Alberto, 22 Dee Taryn, 30 Demirel Esra, 19 Desup Aisulu, 8 Dillen Katherine M., 31 Dimitrov Dobromir, 6, 28 Dolberg Michael, 7 Doran Joseph, 31 Duke Darcy, 27 Dziugieł Sonia, 27 Eguchi Marina, 8 Eissa Ahmed E., 11, 28 Elli Enrique F., 28 Elniel Mohammed, 9-10 Erfani Hadi, 19 Essien Francis, 17 Evans Lorna A., 28 Ewert Ashley, 31 Eyada Mostafa, 20 Eysselein Viktor, 4 Feldman Jeremie, 23 Fontaine Jacques P., 31 Frushour Cheryl, 3 Fullerton Shalyn M., 28 Gallapher Denize, 17 Garrett Joseph R., 31 Gaskins Jeremy, 14 George Shebin, 7 Gratsianskiy Denis, 6 Hajijama Sameera, 13 Hampton Lance J., 23 Han Michelle, 17 Harper Jessica N., 24 Hassan Amar, 13 Hatem Reem, 26 Heidel Robert E., 7 Heldreth Audrey, 6, 12 Hernandez Jennifer, 7 Herron Burnetta, 30 Hoeferkamp Joelle J., 27 Holand Arthur, 14 Holden Marissa, 23 Hooda Zamaan, 11 Horton Courtney, 17 Hudson Macy, 18 Hughes Noemi, 17 Hunter Robert, 7 Hussein Bassem Abou, 13, 26 Imam Adnan, 23 Ivanov Krasimir Dimitrov, 15 Ivanov Yoan, 28 Jain Nutan, 21 Jain Vandana, 21 Jamal Mohammad, 3 Janik Grace, 21 Jones Trevor, 6, 23 Jou Katerina, 5-6, 12 Kalathia Chris, 23 Kalinov Turgay Turgay, 15 Karamanliev Martin, 6, 28 Karunaratne Janani B., 32 Kasakewitch João G., 11 Kasakewitch João P. G., 8-9, 14 Kasakewitch Joao P. G., 8, 10 Kasmirski Julia, 8 Kegel Samantha, 20 Kehdy Farid, 14 Kella Venkata, 15 Kenary Parisa Yazdankhah, 2, 15 Khalfay Nuha, 17 Khammas Ali, 13, 26 Khokar Mohammed Amaan, 13 Kilic Gokhan, 20 Kim Andrew, 3 King Emily H., 20-21 King Natalie, 23 Kleinberg Katherine A., 24 Knewitz Daniel K., 28 Kolev Nikola Yordanov, 15 Koshy Sonia M., 21 Larocca Lucas, 4 Lech Gabriele E., 8, 11 Lee Bruce, 29 Levine Jun, 15 Lewis Gregory, 20 Lewis Karren, 20 Liang Chengbo, 32 Lim-Dy Allyson, 5 Lima Diego L., 10 Lima Diego L., 8-11, 14 Litvinova Katerina, 30 Loe Mallory M., 24 Loui Taylor, 5 Luberice Kenneth, 29 Ma Shani, 20 Mackey Alexandra, 23 Maitra Ishaan, 9 Makhdoom Maahroo, 26 Malcher Flávio, 10 Malcher Flavio, 8 Malik Danial A., 14 Mansour Joseph, 31 Martinez Linda S., 30 Marzouqi Omar, 26 Maslyankov Svilen, 6 Matthaeus Alexander, 21 McManaman Ashelee, 31 Mehdizadeh Alireza, 17 Menghui Zhou, 3 Merida Manuel, 18 Michel Lindsey, 19 Mikhail Emad, 22 Mikhail Joseph, 31 Milone Luca, 30 Milson Blake L., 24 Misra Subhasis, 29 Moodie Carla C., 31 Moore Robert H., 23 Moran-Atkin Erin, 8 Moses Elena, 31 Mukharjee Sourodip, 12-13 Mukherjee Indraneil, 5-6, 11-13, 28, 31 Munver Ravi, 26 Munver Sujan R., 16, 25 Murdock Peyton M., 7 Murphy Colleen, 18 Nemeth Denise, 27 Nemov Valerie C., 22 Nezhat Ceana, 24-25 Nezhat Farr, 19 Ngo Lisa, 7 Nguyen Diana Q., 8, 14 Nguyen Nina, 19 Nguyen Truong, 20 Niedbał Zuzanna, 27 Nimaroff Michael L., 18 Nogueira Raquel, 10 Nogueira Raquel, 11 Novoa y Novoa Victoria Arruga, 31 Nunez Duarte Marie S., 27 Ortiz Karimeh, 27 Otero Javier, 15 Parreco Joshua, 7 Pasquali Claudio, 1 Patel Dhruv, 31 Patel Pooja, 18 Pattilachan Tara M., 3-4, 9 Pavlovic Zoran J., 22 Perez Christian, 4 Perim Victor, 14 Pham Avian, 17 Popover Jesse L., 23 Price Mitchell, 31 Pyke Owen, 15 Q Quintero Luis A., 7 Qureshi Abid, 30 R Rajendran Ilayaraja, 10 Rajvardhan Varnika, 30 Ralston William, 14 Ranjbar Tara, 5-6, 12, 31 Rasador Ana C. D., 9 Rasador Ana Caroline, 8, 10 Rasador Ana Caroline D., 10-11 Rauf Abdul, 25 Reese Chanda, 20 Reicher Sofiya, 4 Rhodes Marvin, 15 Robles Jeffrey, 6, 12, 31 Rochester Summer, 15 Rodriguez Silva Jetsen, 16 Rogando Dillon, 5, 12-13, 31 Rosemurgy Alexander, 3-6, 15 Ross Sharona, 15 Ross Howard, 16, 25 Ross Sharona, 1-3, 5 Ross Sharona B., 4, 6, 9, 11 Rotithor Pandurang Ramchandra, 30 Ruiz Carlos, 11, 28 Russ Andrew J., 7 Russell Caitlin, 5-6 S Sachańbiński Tomasz, 27 Saldivar J. Salvador, 24 Salom Emery M., 21 Sanchez Daphne, 27 Sanha Valberto, 8 Santana Rachel C., 8 Sbeih Mohammed, 1 Schneider Andrew, 15 Schneyer Rebecca, 24 Seaver Christopher, 7 Seifi Farinaz, 18 Shadowen Caroline R., 23 Shalabi Firas, 29 Shapera Emanuel A., 6, 16 Sharma Alexis Behne, 31 Shoshkova Meri, 28 Shu Michael, 31 Siddiqi Shirin, 27 Silveira` Carlos A. B., 8 Silveira Carlos B., 10 Simmerman Neil, 29 Singer Kiara, 5 Singh Kuldeep, 5 Slavin Moran, 3 Snyder Russell, 20 Sooknarine Celine, 18 Sowby Taralyn C., 21 Spector Chelsea, 7 Spector Chelsea L., 7 Sreeramoju Prashanth, 10 Srivastava Sakshi, 21 Stahl Jonathan, 28 Stanley Lauren, 30 Stark Michael, 22 Stephenson-Moe Christoph, 23 Stoklosa Anne, 21 Sturmer Carolina M., 8 Sucandy Iswanto, 1-6, 9, 11, 15 Sukharamwala Kedar, 29 Sukharamwala Prashant, 29 Suzuki Yukiko, 29 Syblis Cameron, 9 Sydnor Mindy, 29 Syed Radha, 18, 30 T Talishinskiy Toghrul, 11 Terrell James E., 4 Tew Jenna R., 31 Than Lee Lee, 23 Toba Nagham, 13, 26 Toloza Eric M., 31 Tong Ernest, 26 Tongkam-Godfrey Ashley, 7 Toomey Paul, 23 Touadi Melissa, 2, 11, 15-16 Tougaw Ryan, 23 Trester Richard, 30 Trimmer-Torres Marina, 27 Truong Mireille, 24 U Uppalapati Pooja, 18 Ur Rehman Ihtesham, 9 Uzianbaeva Liasian, 17 V Vadher Rakshit, 23 Varela Juan, 32 Vargas Carlos E., 22 Vasicka Ian M., 19 Velez Padilla Jonathan, 16 Vidotto Laura M., 8 Vijay Adarsh, 24 Villarreal Lucy, 20 W Wang Pengfei, 17 Wang Xiu-Jie, 17 Wang Zhifei, 3, 23 Wessner Scott, 11 Wilson Afia M., 28 X Xia Jianfu, 3 Xia Minjun, 3 Xia Zhiye, 23 Yaklic Jerome, 20 Y Yetasook Amy K., 4 Yotsov Tsanko, 28 Yotsov Tsanko Ivelinov, 6 Younos Ahmed, 1-2 Youssef Youssef, 19 Z Zhang Yu, 26 Zhou Menghui, 3 Zigouras Sophia, 10 Zlatarov Alexander Kamenov, 15

Objective: We present an 83-year-old male nonsmoker with progressive weakness, rectal bleeding, and 50-lb weight loss. History included iron deficiency anemia, DVT/PE, and stage IV metastatic mesothelioma of the lung, for which he was on apixaban and immunotherapy. EGD revealed erosive gastritis and a friable prepyloric mass positive for signet ring cell carcinoma causing gastric outlet obstruction. Initially a covered stent was placed; however, after initial reluctance to surgery, the stent migrated. It was removed and replaced. The objectives were to remove the mass and resolve the obstruction and bleeding. Methods: He underwent a laparoscopic distal gastrectomy, Billroth II gastrojejunostomy, and stent removal. After adhesiolysis and lymph node harvesting, the stomach and duodenum were transected using a linear stapler. A gastro-jejunostomy were created with a linear stapler and sutures. Transversus abdominis plane blocks were performed before closure. Results: The pathology was positive for poorly differentiated signet ring cell carcinoma and metastatic carcinoma in one of 17 lymph nodes. Postoperatively, he had successful diet advancement, return of bowel movement and flatus, and good gastric emptying. He has resumed his normal routine and continues immunotherapy for mesothelioma and gastric cancer surveillance. Conclusions: New gastric signet ring cell carcinoma with metastatic malignant mesothelioma is uncommon. With such presentations, surgery can be high risk but necessary for palliation, with possible curative intent. The extent of intervention should be agreed upon between surgeon and patient and aim to improve quality of life.

Background: Trocar site hernia (TsH) is a less common complication of laparoscopic bariatric procedures. The aim of this study is to investigate whether fascial closure (FC) or nonfascial closure (NFC) of the trocar site, in patients undergoing bariatric surgery, will affect the incidence of TsH. Methods: A systematic review was conducted from July to September of 2023 and registered on Prospero 2023 CRD42023403504. The study included articles of patients that had bariatric surgery describing the closure technique and TsH incidence, and excluded procedures using a single port, natural orifice, open or robotic technique. Search engines included PubMed, Medline, Scopus, and ClinicalTrials. The risk of bias was assessed using standard tools. Results: Of the 1,433 screened studies, 14 articles consisting of 5,232 participants met the eligibility criteria, which consisted of only cohort studies. Of the 14 studies, only 3 compared the development of TsH between the FC and NFC groups. Two of the 3 reported a significantly increased incidence of TsH in the NFC group ( P  = .02, P  < .05), whereas the remaining study reported no significant difference in incidence between both groups. Eleven of the 14 studies did not compare the incidence of TsH between FC and NFC. Six studies only included patients that underwent FC, while 5 studies only included NFC. The study’s limitations were data heterogeneity and lack of adequate comparative literature. Conclusions: This systematic review revealed equivocal results Further studies must be conducted with more statistical evidence to formally declare an association.

Background: Inguinal hernia in male is common hernia. On the other hand, proper surgical treatment of female inguinal hernia and its outcome is insufficient. As a result, the experience of managing inguinal hernia outcomes in females is reported. Materials and Methods: The female patient diagnosed with inguinal hernia from May 2016 to May 2023 were involved in this study. Results: Eleven female patients complain of groin pain mainly and swelling; the pain is severe. All patients were operated with laparoscopic retromuscular mesh repair. One patient has a femoral hernia only, 2 patients had a femoral hernia, an inguinal hernia, and 1 patient has a bilateral inguinal hernia. Female patients have more inguinal fat in the inguinal canal. All cases were discharged within one day postoperatively. No recurrence or chronic pain was encountered. Conclusion: Laparoscopic retromuscular mesh repair for inguinal hernia and canal is a better approach to discovering misdiagnosed femoral hernia, combined femoral and inguinal hernia. Moreover, a bilateral inguinal hernia is managed by the same incisions, additional laparoscopy spares nerves, and cosmetics for females.

Objective: To determine whether postoperative pain management following gynecologic laparoscopy differed based on patient race or socioeconomic status at a single institution. Methods and Procedures: We performed a retrospective cohort study of all patients who underwent laparoscopy for benign gynecologic indications from January 1, 2016 to January 1, 2023 at a single academic institution. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and classified by age, race, ethnicity, BMI, type of insurance, and surgery class. Associations were estimated by univariable analysis and multivariable logistic regression. Results: We identified 3,376 patients who met inclusion. Case characteristics were similar between all groups. We found no difference in MME prescriptions based on patient age, BMI, or type of insurance. Women undergoing major surgery were given higher doses of opiates upon discharge than those undergoing minor surgery. White and black patients were discharged with significantly higher doses of opioids when compared with Hispanic patients ( P  = .01). Conclusion: Studies published in the obstetric and pediatric populations have found disparities in postoperative pain management in nonwhite patients and patients of lower socio-economic status. To the best of our knowledge, no study of this kind has been performed in patients who have undergone laparoscopic surgery for gynecologic indications. Our results indicate that disparities exist in postoperative pain prescription practices at our institution. These findings could influence prescribing habits in providers to help improve these disparities in our population, and highlights the importance of establishing more uniform, evidence-based guidelines for postoperative pain management.

Objective: Additional support regarding the safety and feasibility of combined paraesophageal hernia (PEH) repair and Roux-en-Y gastric bypass (RYGB) is needed. We sought to analyze both the short- and long-term outcomes of patients who underwent this combined operation. Additionally, we aim to supplement the limited literature reporting outcomes following robotic surgery. Methods and Procedures: We performed a single institution retrospective analysis of overall morbidity and mortality of patients who underwent primary RYGB with PEH repair from January 2014 to July 2023. Results: Fifty-two patients were included. Mean preoperative BMI was 40 kg/m 2 . The mean follow-up period was 14 months. Most operations were performed robotically (59.6%). A robotic approach was associated with a significantly decreased operative time along ( P  = .05) with decreased symptomatic recurrence ( P  = .163). Six and 3 patients were noted to have minor and major post operative complications, respectively. Significant improvement in GERD, OSA, HTN, and HLD was noted by last follow-up. We report an average excess weight loss (%EWL) at 1, 3, 6, 12, and 24 months of 18%, 35.3%, 47.1%, 56.6%, and 62.2%, respectively. Conclusions: To the best of our knowledge, our report represents the largest single institution analysis of patients who underwent combined PEH repair with RYGB, and one of the few reporting outcomes following its completion via a robotic approach. Although this combined operation is feasible, the addition of PEH repair may be associated with increased risk of postoperative complications.

Objective: Bipolar radiofrequency ablation is a second-generation endometrial ablation procedure for treatment of abnormal uterine bleeding. It is associated with a high success rate and major complications are rare. Thermal bowel injury is an uncommon but serious complication of bipolar radiofrequency ablation. This case illustrates the most extensive thermal bowel injury described in literature from bipolar radiofrequency ablation. The objective of this case report is to highlight a catastrophic procedure complication and emphasize the importance of device-specific patient safety initiatives. Methods and Procedures: A 41-year-old G3P2012 with history of abnormal uterine bleeding and 2 cesarean sections postoperative day 6 after bipolar radiofrequency ablation and hysteroscopy presented to the emergency department with abdominal pain, nausea/vomiting, obstipation, and anorexia since the procedure. General surgery, interventional radiology, and infectious disease were consulted. Serial computed tomography abdomen/pelvis studies revealed worsening pneumoperitoneum and intraperitoneal free fluid concerning for bowel perforation. Emergent exploratory laparotomy was performed. Seven bowel perforations and a uterine perforation were identified. Right hemicolectomy, enterectomy with primary anastomosis, and rectosigmoid resection with end-colostomy were performed. Postoperative course was complicated by ileus. Patient was discharged on postoperative day 24. Results: Seven thermal proximal ileum, terminal ileum, right colon, and rectal sigmoid perforations with severe serositis and cautery artifact were confirmed by pathology. Conclusion: Bowel injury secondary to bipolar radiofrequency endometrial ablation is a rare but grim complication. Ongoing improvement of device deficiencies, standardized ablation device training, and perioperative briefing protocols are advised strategies to minimize procedure complication rates.

Objective: The escalating prevalence of obesity has emerged as a pressing public health concern. The ever-expanding array of bariatric surgical options available in modern medicine emphasizes the need for comprehending the evolving interests of patients. Subsequently, this study seeks to analyze and compare the temporal trends of online searches pertaining to bariatric surgery queries. Methods and Procedures: Search terms related to bariatric surgery included, “Weight loss surgery,” “Bariatric surgery,” “Sleeve Gastrectomy,” “Gastric Sleeve,” “Lap Band,” “Adjustable Gastric Band,” “Roux-en-Y,” and “Gastric Bypass.” Google Trends was employed to acquire the relative search volume (RSV) at the United States state and national level. This analysis spanned from 2004 to 2021. Results: United States national analysis revealed a 1.6-fold increase in RSV for weight loss surgery and bariatric surgery, and a remarkable 48.7-fold surge in interest for sleeve gastrectomy and gastric sleeve (both P  < .00001). Conversely, there was a 2.1-fold decrease in RSV for lap band and adjustable gastric band, as well as a 1.8-fold decrease for Roux-en-Y and gastric bypass (both P  < .001). State analysis consistently showed highest RSV stemming from the geographic southern United States. Conclusion: This study demonstrates a consistent rise in search queries for bariatric surgery since 2004. The data suggests patient's growing inclination towards self-education on surgical weight loss options especially in the southern United States. These findings serve as a valuable guide to multidisciplinary approaches for weight loss and highlights the importance of fostering open discussions of obesity management strategies with patients.

Objective: In 2009, we designed the sutureless “Slim-Mesh” laparoscopic procedure to facilitate and promote the repair of ventral hernias in the obese/superobese populations, including cases with large-giant/massive ventral hernias. We also aimed to reduce operation time and intra- and postoperative complications. Methods and Procedures: We divided our obese cases into Class I (BMI 30.0–34.9 kg/m 2 ), II (35.0–39.9 kg/m 2 ), III (40.0–49.9 kg/m 2 ), and Superobese (50.0–59.9 kg/m 2 ). A ventral hernia was small-medium, or large-giant/massive when its diameter measured 2–9.9 cm, 10–14.9 cm, 15–19.9 cm, and ≥ 20 cm, respectively. Between September 2009 and May 2023, 64 obese/superobese ventral hernia patients were enrolled prospectively (81%)-retrospectively and treated with the “Slim-Mesh” technique. Results: We operated on 35 males and 29 females. Mean age and BMI were 60 years old and 33 kg/m 2 , respectively. Class I cases numbered 48, II 13, III 2, with 1 superobese case. Small-medium, large-giant/massive ventral hernia were found intraoperatively in 40, 21, and 3 cases respectively. Mean operation time for all cases was 104 minutes. Mean length of hospital stay was 2 days and follow-up time was 5 years. We had one case of chronic abdominal-wall pain and 6 late postoperative-complications: 4 (6%) hernia recurrences and 2 trocar-site hernias. Conclusion: The sutureless “Slim-Mesh” technique implements the laparoscopic approach to repair ventral hernias in the obese/superobese populations rather than open surgery or traditional transfixation suture-based laparoscopy, including cases with large/giant/massive hernias. In our experience, “Slim-Mesh” proved to be safe, straightforward, quick, easy-to-reproduce, and economical.

Introduction: Bile duct injuries (BDI) are a serious complication during laparoscopic cholecystectomy with uncertain outcome even when detected and repaired early. The most common cause for BDI is poor visualization of the structures in the triangle of Calot. Fluorescent cholangiogram is a novel technique aimed at reducing the rates of BDI. Materials and Methods: Three different doses of ICG (0.05 mg/kg, 1 and 2 mg) were injected at 3 different time periods (1, 3, 6 hours) prior surgery. Images of the anatomy of the bile ducts anatomy were obtained under white light and near infrared (NIR) light for all cases. Questionnaire containing side-by-side pictures of the anatomy under wight light and NIR light was prepared and uploaded on Google Forms. The survey was sent to different practitioners and the result were collected anonymously. Results: The survey had 122 responders. According to them the most optimal image of the fluorescent cholangiogram was obtained with 1 mg ICG injected 3 hours preoperatively. The worst case was presented when 0.05 mg/kg ICG was injected 1 hour preoperatively. Only 16.4% report routine use of the method. However more than 80% find the method useful. Nearly 70% of the surveyed report that they would use the method, if they had access to it. Conclusion: Even though, there are few surgeons that routinely use the method, most the responders affirm that the method is useful and more than half are willing to use the method routinely, if they have access to it.

Objective: Bilateral oophorectomy during hysterectomy is often performed at time of hysterectomy for endometriosis-associated pain. The purpose of our study is to evaluate pain outcomes in women undergoing hysterectomy and radical resection of endometriosis with ovarian conservation. Methods and Procedures: Retrospective clinical case series of patients undergoing hysterectomy and radical resection of endometriosis with ovarian conservation in advanced staged endometriosis between 2014 and 2022 from a single surgeon. Inclusion criteria included premenopausal patients age >18 undergoing hysterectomy and radical resection of endometriosis with ovarian conservation for endometriosis-associated pain. Exclusion criteria included patients who had prior hysterectomy, BSO at time of hysterectomy, malignancy or precancer, or were loss to follow-up. Patients were contacted via telephone for follow-up. Descriptive analysis was utilized. Results: A total of 53 patients were evaluated; 38 patients excluded and 15 met inclusion criteria. The mean reported improvement of pain since surgery was 95% (SD 13). The mean preoperative pain score was 8.69. Postoperative pain score means were 1.56, 1.2, 0.57, 0.58, and 1.13 and 0.78 at 1, 2, 3, 4, 5 years and current pain score respectively. The median and mean follow-up were 56 and 69.5 months respectively. The mean operative time was 111 minutes (SD 43.6). N = 1 (6.25%) had an intraoperative complication and n = 3 (20%) had a post op complication. N = 2 (13.33%) required reoperation. Conclusion: Patients undergoing definitive surgery with hysterectomy and routine excision of all endometriosis with ovarian conservation have long-term pain relief which avoids the detrimental effects of early onset menopause. ★ Gustavo Stringel Award for Best Poster

Objective: Report a comparison of conservative and radical laparoscopic management of bilateral hydroureter due to ureteral endometriosis in a woman with severe deep infiltrative endometriosis. Methods and Procedures: A 30-year-old nulliparous woman with previous diagnosis and treatment of umbilical endometriosis presented with pelvic pain and bilateral hydroureter. The patient had continued hydroureter with distal ureteral stricture after initial extensive ureterolysis on right ureter. She underwent right ureterolysis and ureteroneocystostomy with psoas hitch. Post operatively she did well, and left ureter was managed conservatively with ureteral stent as needed. Two years later worsening symptoms required surgical management of the left ureter with extensive ureterolysis, partial wall resection and repair secondary to absence of intrinsic disease. Currently, she has been followed for 10 years from the right ureteroneocystostomy and 8 years from left ureterolysis, ureteral wall resection and repair. Nuclear medicine renal function scans throughout the follow-up years reveal right side function of 37% and left sided function of 63%. Results: Treatment of bilateral hydroureter. Conclusion: This case demonstrates the long-term renal function with conservative surgical management of one ureter and radical surgical management of the contralateral ureter in the same patient. Current recommendation of routine ureter resection and reimplantation for extrinsic distal ureteral endometriosis may be inferior to conservative ureterolysis and excision of endometriosis.

Introduction: Cholecysto-duodenal fistula is a rare complication of chronic calculous cholecystitis. Due to advancement in minimally invasive techniques, a paradigm shift has occurred from the traditional open surgery to laparoscopic repair but only one case report highlights robotic repair. In this article, we report a case of cholecystoduodenal fistula management by robotic approach. Case Report: A 50-year-old female with history of laparoscopic Roux-en-Y gastric bypass surgery and total abdominal hysterectomy presented with intermittent, postparandial right upper quadrant abdominal pain, associated with diarrhea. Abdominal ultrasound showed cholelithiasis with dilated common bile duct, that did not contain gallstones based on magnetic resonance cholangiopancreatography. She was taken to the operating room for robotic assisted laparoscopic cholecystectomy, where she was found to have cholecystoduodenal fistula which was divided robotically. The patient had an uneventful recovery. Discussion: Patients with cholecysto-duodenal fistula often present with nonspecific signs and symptoms and preoperative diagnosis of cholecysto-enteric fistulas remains a challenge. Once diagnosed intraoperatively management has ranged from laparoscopic repair to open surgery. This case report discusses the advantage of enhanced visualization of dense adhesions in 3 dimensions by the robot, eliminating the need for conversion to open surgery.

Objective: Inguinal hernias are a common occurrence with a lifetime risk of 27% and 3% among men and women, respectively. Passage of retroperitoneal organs through the abdominal wall defect is known as sliding inguinal hernias. Methods and Procedures: A 60-year-old male with a known history of hypertension and previous open appendectomy presented with a 10-year history of unilateral scrotal swelling associated with suprapubic discomfort. Physical examination revealed bilateral inguinal hernias, with a larger nonreducible hernia sac on the left. Preoperative noncontrast CT confirmed the presence of the urinary bladder wall within the left hemi-scrotum. Results: The patient underwent robotic-assisted repair of bilateral inguinal hernias. Intraoperatively, multiple dense intra-abdominal adhesions beneath the umbilicus and the site of previous open appendectomy were seen. Extensive lysis of adhesions was performed and peritoneal flaps were created. A large right-sided direct, indirect and femoral hernia was discovered and subsequently reduced. On the left, a 15-cm hernia sac consisting mainly of fat was reduced through a 4 × 6 cm defect in the abdominal wall - likely containing the urinary bladder. Primary closure of the defects was achieved and bilaterally, polypropylene mesh was inserted into the peritoneal flaps to reduce the risk of recurrence. Conclusion: Robotic-assisted repair represents a safe approach for managing complex inguinal hernias, including sliding bladder hernias. This approach allows for direct visualization of the hernia sac, intraoperatively, which may reduce iatrogenic injury to the bowel during repair. This case underscores the feasibility of robotic surgery in achieving favorable outcomes and importance of individualized treatment strategies in inguinal hernia management.

Objective: Bladder neck contracture (BNC) is typically managed with transurethral endoscopic techniques. If these approaches fail, bladder neck reconstruction may be considered. We present a 56-year-old male with recurrent BNC after robotic-assisted radical prostatectomy. Postoperatively, he developed reactive thrombocytosis and urinary clots, leading to BNC after traumatic Foley catheterization. Despite 8 unsuccessful endoscopic procedures, he underwent robotic-assisted Y-V plasty bladder neck reconstruction. We demonstrate our surgical approach. Methods and Procedures: A multiport transperitoneal approach was used. Guided by cystoscopic transillumination, the anterior bladder neck was incised in a Y shape to avoid the external sphincter and expose healthy urethra. Fibrotic tissue was excised to create a V-shaped bladder flap. A running anastomosis was performed, and the bladder was filled to ensure a watertight closure. A bioregenerative amniotic membrane allograft was placed over the anastomosis for healing and as an adhesion barrier. The peritoneal defect was closed. A Foley catheter and drain were placed. Results: Operative time was 2 hours and 58 minutes. EBL was less than 5 mL. The patient had an uncomplicated postoperative course and was discharged on postoperative day 1. Cystogram and Foley catheter removal was performed on postoperative day 10. At 3-month follow-up, cystoscopy confirmed bladder neck patency, and the patient continues to void without urinary incontinence at 1 year. Conclusion: Robotic Y-V plasty bladder neck reconstruction may be offered for the treatment of recurrent BNC in patients with prior endoscopic treatment failure. This complex reconstructive procedure introduces healthy tissue to the fibrotic bladder neck, promotes healing, and can improve quality of life. ★ Best Urology Video

Objective: Combined minimally invasive colon resection together with other major procedures has been shown feasible and safe. Rarely this is done for independent pathologies. Methods and Procedures: A 35-year-old female with learning disability presented with 30 pounds weight loss during the past year, fatigue, and stool irregularities. On workup she was found to have iron deficiency anemia. Her BMI was 28 kg/m 2 . Colonoscopy showed a cecal and descending colon mass and biopsy revealed adenocarcinoma. CT-scan also showed a small hiatal hernia. Results: She underwent uneventful laparoscopic right and left colectomy with ileocolic anastomosis and end colostomy; the sigmoid colon was preserved for future reconstruction. Pathology revealed T3N1aM0 and T3N0M0 adenocarcinomas and she underwent adjuvant chemotherapy. Workup showed no evidence of recurrent cancer, however, she had gained significant weight (BMI now 35 kg/m 2 ) and developed ostomy prolapse and a parastomal hernia and CT-scan showed the PEH had significantly increased in size and she developed GERD and dysphagia. After supervised weight loss, she underwent combined laparoscopic/robotic colostomy closure and paraoesophageal hernia repair. She had a slow recovery with ileus and gastric distention and a PEG was placed for drainage. She was discharged but returned to the ER with a small bowel obstruction and underwent exploratory laparotomy revealing a mesenteric mass and a Meckel diverticulum which were resected. Pathology showed benign desmoid fibromatosis. She is well after 2 years. Conclusions: The case confirms that patients will benefit from a minimally invasive approach in complex abdominal surgeries. The robot was found beneficial in this case. Click here to view the MISWeek 2024 Disclosure Index

Objective: A modified technique was developed for primary trocar entry to reduce risk of serious injury to vessels and internal organs like bladder and bowel. This technique enhanced patient safety by addressing the potential complications associated with traditional trocar entry methods. Methods and Procedures: There are 2 layers in abdomen that need sharp instrument to penetrate—skin and rectus sheath. The skin was cut as usual. The subcutaneous fat was separated by blunt end of blade. Towel clip was anchored to skin below incision and pulled up by the surgeon’s nondominant hand in such a way that a “blunt conical” trocar enters at 90° to the incision and at 30° to horizontal. A small incision was made by blade on rectus sheath in the intended direction of trocar insertion and a stopper was employed over the trocar sheath to prevent overshooting. The clip pull gave firm grip even in cases of toned abdomen. The countertraction from towel clip made trocar entry independent of an assistant. Results: This modified technique has been successfully applied in numerous cases, demonstrating its efficacy in minimizing the risk of trauma to internal organs. This method was faster and safer than traditional techniques such as the Veress needle entry or Hassan’s technique, showcasing its potential for widespread adoption. Surgeons new to laparoscopy found the technique easier to adopt. Conclusion: By addressing the limitations of existing methods, this technique offers a faster, safer, and more consistent approach to trocar entry.

Pancreatic necrosis is a severe complication of acute pancreatitis, often requiring surgical intervention. Traditional open necrosectomy has significant morbidity and mortality, prompting the development of minimally invasive techniques. This study analyzes the outcomes of minimally invasive necrosectomy at a single institution. Demographic data and perioperative outcomes of laparoscopic necrosectomy cases from August 2015 to October 2023 were analyzed using χ 2 analysis and the Mann-Whitney U -test. Data are presented as median (mean ± standard deviation). Twenty-one patients (17 men, 4 women) underwent laparoscopic necrosectomy, with an average age of 58 years (±14.8) and a mean body mass index of 26.2 kg/m 2 (±6.3). The causes of pancreatitis included pseudocysts (n = 4), gallstone pancreatitis (n = 7), alcohol-related pancreatitis (n = 5), recurrent pancreatitis of unspecified etiology (n = 4), and pancreatic cancer (n = 1). Lesion size averaged 14.1 cm (±5.4). Intraoperative findings highlighted an average estimated blood loss of 132.8 mL (±243.0) and an operative time of 126.8 minutes (±50.4). Postoperative outcomes indicated a median hospital stay of 8.3 days (±6.5), with drain placement in 90% of cases for an average of 53.7 days (±43.7). There was no in-hospital mortality. Seventy-five percent of patients were discharged home, and 25% were transferred to assisted living facilities. The readmission rate was 37%, with one reoperation for intra-abdominal fluid collection. These findings underscore that minimally invasive necrosectomy for pancreatic necrosis can reduce mortality and improve recovery. Despite the high readmission rate, the significant percentage of patients discharged home suggests favorable short-term outcomes. Further research is needed to optimize patient selection and reduce readmission rates.

Objective: The purpose of our video is to demonstrate minimally invasive robotic-assisted endometriosis excision and ureter transection and reimplantation in the case of stage IV endometriosis wherein a patient’s ureter was obstructed by endometriosis implant. Methods and Procedures: Two surgical teams—gynecology and urology—collaborated to perform this case and edit this video submission. Results: Our patient’s case was successful and she had excellent improvement in her presenting symptoms. Conclusion: For patients with stage IV endometriosis involving other organ systems like the urologic tract, surgical procedures may be performed using minimally invasive methods to relieve their symptoms. Collaboration between surgical teams is imperative to good outcomes.

Robot-assisted surgery (RAS) is a revolutionary technology for the surgeons, doctors, and physicians. Although RAS deployment is rapid since 2019, despite decades of successful robotic assisted surgeries in the developed economies that have positively impacted millions of patients, RAS was barely explored by the developing countries compared to the developed countries whereby capabilities to enhance and improve the levels of expertise is limited besides acquisition and operating costs. This paper aims to investigate what is the future of RAS in selected developing countries given its multitude of needs and challenges? Is RAS still in early days too expensive to be put to general use in these developing economies today? We applied indicators to test the adoption of RAS using economic consideration of robotic surgery in health economics. We examine the likelihood of acquiring and using RAS with different market characteristics from 2000 to 2022. We used data on traditional and robot-assisted surgical interventions and transform it into an improved version on Quality-Adjusted Life Year and Willingness-to-Pay for Robot-Assisted Surgery. Asia growth was spectacular. China’s participation resulted in closing the gap much faster in advanced medical technology and RAS treatment between developing and developed economies beside knowledge diffusion. South Koreans had catch up with the Europeans, ie, Italy, Germany, France, and United Kingdom. Since 2015, Singapore had a huge improvement rapidly towards competing with United States, while China has tremendous progress leap over Malaysia and Thailand. China’s total patents had explosive growth and the robot density was among the highest among the selected economies compared in this study.

Objective: Pediatric foreign body ingestion (FBI) is a healthcare concern that affects more than 100,000 children in the United States annually. The risk of ingestion is high among children with neurodevelopmental and intellectual disability (ND-ID). Ingestion of large, sharp or caustic substances may lead to significant morbidity and mortality through gastrointestinal fistula formation or perforation. Methods and Procedures: A 15-year-old male with severe autism spectrum disorder (ASD), significant ND-ID and a history of previous FBI of metal objects, such as outlet plugs, presented to the ED with a 1-day history of right sided abdominal pain, nausea, and bilious vomiting. Initial examination revealed RLQ tenderness without guarding or rebound. CT Abdomen and Pelvis demonstrated aggregated metallic objects without evidence of perforation. Due to low likelihood of spontaneous foreign bodies passage, and risk of perforation, the patient was brought urgently to the OR for exploratory laparotomy and removal of the foreign bodies. Results: Intraoperatively, multiple fistulas were discovered. One gastrojejunal fistula and 2 jejuno-jejunal fistulas of varying chronicity were identified, suggesting chronic FBI. Involved-sections of small bowel were resected and a side-to-side stapled anastomosis was performed. The patient’s postoperative course was uncomplicated. His diet was advanced and was subsequently discharged on POD7. Patient is tolerating a normal diet well without abdominal pain or change in bowel movements 2 weeks postoperatively. Conclusion: Clinical suspicion of FBI should be high among children with ND-ID presenting with abdominal pain, followed by prompt surgical evaluation and intervention to prevent adverse outcomes such as bowel necrosis, perforation, and mortality.

Objective: Laparoscopic cholecystectomy is the “gold standard” surgical approach for acute cholecystitis. Recently, there has been increased interest in robotic-assisted cholecystectomy for acute cholecystitis and its outcomes compared to the laparoscopic approach. Currently, there is a paucity of literature pertaining to this topic. This study compares length of operative time and clinical outcomes between these 2 techniques. Methods and Procedures: A 1-year retrospective analysis at a single institution was performed of patients that underwent laparoscopic or robotic-assisted cholecystectomy. Patients excluded included those undergoing elective cholecystectomy, cases involving intraoperative cholangiogram and final pathology inconsistent with acute cholecystitis. The variables compared were length of operative time, postoperative complications and conversion to open cholecystectomy. Unpaired t -test was utilized to compare the collected information. Results: A total of 103 total patients (55 in the laparoscopic cholecystectomy group, 48 in the robotic-assisted cholecystectomy group) were included in the study. Average operative time for laparoscopic cholecystectomy was 108.6 minutes (SD of 25.7 minutes) and 104.1 minutes (SD of 18.6 minutes) for robotic-assisted cholecystectomy ( P = .32). Three patients had postoperative complications with the laparoscopic cholecystectomy approach. Zero cases of postoperative complications occurred with the robotic-assisted approach ( P  =   .10). Conversion to open cholecystectomy occurred once with laparoscopic cholecystectomy, which was not required during any of the robotic-approach cases ( P = .35). Conclusion: Our data indicate that robotic-assisted cholecystectomy is a feasible option for the treatment of acute cholecystitis. Our data suggests that the robotic approach is associated with decreased operative time, less risk of postoperative complications and open conversion. ★ Michael S. Kavic Award for Best Scientific Paper by a Resident

Objective: The study aims to evaluate the effectiveness and safety of a contained excision technique utilizing a robot-assisted approach for the cytoreductive surgery of a recurrent ovarian carcinosarcoma in a 74-year-old patient. Methods and Procedures: A minimally invasive secondary cytoreductive surgery was planned for a patient with a history of stage IIIa ovarian carcinosarcoma, who presented with local recurrence. The procedure began with a global survey of the intraperitoneal cavity with no visible tumors were found in the abdominal area. Extensive lysis of adhesion was performed to optimize visualization in the pelvis, where the recurrent tumor was identified on the left pelvic sidewall. Two key principles were followed: extensive dissection of the surrounding tissue to access the tumor base and avoidance of direct tumor handling. Results: The recurrent tumor was successfully removed without direct contact using the contained excision technique. The procedure resulted in minimal estimated blood loss (50 cc), no complications, and the patient was discharged on the same day. Histologic and molecular evaluation of the excised mass confirmed poorly differentiated carcinoma. Pelvis remained disease free following surgery. Patient is receiving adjuvant systemic treatment following surgery and for suspected liver tumor implants. Conclusion: The contained excision technique, as part of a robot-assisted surgery for recurrent ovarian cancer, is feasible and should be considered to reduce the risk of tumor spillage. The successful execution of this technique with minimal blood loss and no complications supports its adoption in suitable cases.

Objective: Amidst concerns about surgical training’s impact on patient care, this study aims to evaluate the outcomes and safety of bariatric surgeries, including robotic and laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with resident participation. Methods and Procedures: Cochrane, PubMed/MEDLINE, and Embase databases were searched on studies that compared outcomes of bariatric surgeries performed with resident involvement against those conducted by attending surgeons alone. The selection process was carried out by 3 independent reviewers, with any disagreements being adjudicated by a fourth reviewer. Results: From 750 records, 25 studies were included, encompassing 1,818,940 patients, of whom 382,661 (21.0%) underwent bariatric surgery with resident participation. Our findings indicate that surgeries involving residents were associated with a reduced risk of postoperative bleeding (RR 0.68; 95% CI 0.49–0.96) compared to those performed by attending surgeons alone. Conversely, surgeries without resident involvement showed a higher risk of small bowel obstruction (SBO) and large bowel obstruction (LBO) (RR 1.56; 95%CI 1.31–1.85). No significant differences were observed in ICU admissions, anastomotic leakage, mortality, readmission rates, reoperations, or SSI. Conclusions: Resident participation in bariatric surgeries does not compromise patient safety and may enhance certain postoperative outcomes. This supports the integration of residents in bariatric surgical teams, emphasizing the importance of hands-on training in surgical education without adversely affecting patient care.

Objective: To describe a reproducible, step-by-step technique for excising vaginal deep endometriosis in patients who desire future fertility. Methods and Procedures: Our patient is a 34-year-old female G1P1001 who presented with chronic pelvic pain, dyspareunia, and dysmenorrhea with a history of an uncomplicated cesarean section. Transvaginal ultrasound and MRI both revealed extensive deep endometriosis, with a large nodule invading the posterior fornix and rectum. Vaginoscopy was first performed to visualize the lesion and assess its invasiveness into the posterior fornix. Then, via a minimally invasive technique, the medial pararectal spaces were dissected and opened bilaterally followed by dissection of the rectovaginal space to isolate the rectum. The large endometriotic nodule was bisected, with half invading the anterior rectum and half invading the vagina. Next, colorectal surgery resected the affected portion of the rectum. The endometriotic lesion invading the posterior vagina was then resected, followed by resection of any residual lesions at the margins to prevent disease recurrence. Finally, the colpotomy was closed and reanastomosis of the rectum was performed. Results: In a patient desiring fertility sparing surgery, deep endometriosis invading the vaginal canal and rectum was successfully resected while also preserving the patient’s normal anatomy. Conclusion: Vaginal endometriosis is an underappreciated and underrepresented form of endometriosis and can be challenging to diagnose and treat, yet it is often a marker of more advanced disease. The surgical technique we present offers a treatment option for women with deep vaginal endometriosis that could provide both symptomatic relief and help achieve future fertility goals.

Objective: Acute kidney injury (AKI) is associated with increased postoperative mortality after cardiac surgery, but this relationship is not well-studied for pulmonary surgery. We aimed to determine effects of increases in serum creatinine on postoperative outcomes after pulmonary lobectomy. Methods and Procedures: We retrospectively analyzed patients who underwent robotic-assisted pulmonary lobectomy by one surgeon over 13-years. A modified Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI grouped patients based on 0.3 mg/dL increase in serum creatinine within 48 hours after surgery or 1.5-fold increase from baseline within 1 week after surgery. Those with end stage renal disease or who have undergone renal replacement therapy were excluded. Perioperative outcomes were compared using Student’s t , Mann-Whitney U , and χ 2 (or Fisher’s exact) tests, with significance at P  ≤ .05. Results: Of 797 study patients, 71 (8.9%) met KDIGO criteria for AKI. Overall postoperative complications were higher in AKI vs non-AKI patients ( P  < .001). Postoperative pneumonia rates differed ( P  < .001), but postoperative atrial fibrillation rates were not significantly different ( P  = .063) between study groups. Hospital length of stay (LOS) was higher in AKI versus non-AKI patents ( P  < .001). Median LOS in AKI patients was 7 days vs 4 days in non-AKI patients. In-hospital and 30-day mortality rates were 12.7% (n = 9) and 15.5% (n = 11), respectively, for AKI patients versus 0.41% (n = 3) and 0.55% (n = 4), respectively, for non-AKI patients. Conclusions: Patients with KDIGO-defined AKI have more postoperative complications, especially postoperative pneumonia, and higher in-hospital and 30-day mortality. Creatinine should be monitored closely, and even minor AKIs should be treated promptly to prevent adverse outcomes.

Objective: Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome is a rare congenital anomaly affecting 0.1–3.8% of the female population. First line management is with vaginal septum excision however when recurrence occurs management options vary. The objective of this video is to demonstrate in patients with OHVIRA syndrome and recurrence of vaginal septum, hemihysterectomy with hemivaginectomy is a reasonable definitive option and can be completed minimally invasively. Methods and Procedures: A 16-year-old female with OHVIRA syndrome and recurrence of vaginal septum after resection is presented. Recurrence occurred 6 months after the initial surgery. She underwent subsequent diagnostic laparoscopy and attempted re-excision of the vaginal septum which was unsuccessful and ultimately opted for definitive management with minimally invasive robot-assisted hemihysterectomy and hemivaginectomy. Results: The patient underwent uncomplicated robot-assisted hemihysterectomy and hemivaginectomy and recovered well without complications. Conclusion: Although vaginal septum excision is the mainstay of treatment in most cases and recurrence is rare, minimally invasive hemihysterectomy with hemi-vaginectomy is a reasonable and definitive option after recurrence or when septum excision cannot be performed safely. ★ Carl J. Levinson Award for Best Video

Objective: Childhood and adolescent obesity is a significant public health concern in the United Arab Emirates (UAE). Although bariatric surgery is a well-established treatment for severe obesity in adults, its effect on quality of life (QoL) in the younger population is still underexplored. We aim to investigate the QoL of adolescent patients who undergo bariatric surgery in the UAE. Methods: A retrospective cross-sectional study was conducted on 44 adolescent patients with severe obesity who underwent bariatric surgery between 2013 and 2020. The Bariatric Analysis and Reporting Outcome System (BAROS) QoL questionnaire was administered via phone calls after a minimum 2 years follow-up. Results: A total of 44 patients ≤18 years old were included, 64% of patients were female. Their initial BMI was 47 ± 6 kg/m 2 and an average percent of 95th percentile of 157 ± 20%. Most patients underwent laparoscopic sleeve gastrectomy (91%) and the remaining underwent one anastomosis gastric bypass. They experienced a total weight loss of 38 ± 11% and an excess weight loss of 76 ± 22%. The BAROS questionnaire revealed that 14% of patients had excellent and 38% had very good outcomes (31% good, 12% fair, and 5% failure). Patients reported high levels of satisfaction in self-esteem, social, labor, and physical appearance-related domains on a 5-point scale (4.6 ± 0.8, 4.9 ± 0.5, 4.7 ± 0.7, and 3.8 ± 1.0). Conclusion: Adolescent bariatric surgery is a promising solution for severe obesity experienced in this age group. Our data indicate a high rate of positive outcomes and QoL across all domains. ★ Gustavo Stringel Award for Best Pediatric Surgery Presentation

Objective: Placental site nodule (PSN) is a rare benign remnant of intermediate trophoblastic cells in uterine or extrauterine sites, such as a cesarean scar defect, or isthmocele. There are several surgical approaches described for isthmocele repair, however, no surgical approach has been identified as superior. For desired surgical management and uterine conservation, laparoscopic repair can be considered. The objective of this video is to demonstrate a minimally-invasive robot-assisted laparoscopic resection of a PSN within an isthmocele. Methods: A 39-year-old female with pelvic pain and a history of one prior cesarean section was found to have a cesarean scar defect. She preferred uterine-conserving treatment and opted for robot-assisted laparoscopic repair. Postoperative ultrasound revealed resolution of isthmocele and symptoms resolved after 6 weeks. Results: The patient underwent uncomplicated robot-assisted isthmocele repair. Surgical pathology of the resected scar revealed a PSN. PSN is rarely seen clinically, however, can masquerade on ultrasound as other etiology including polyps or scar defects. Conclusion: Although there is no superior surgical technique currently described for isthmocele repair, a minimally-invasive laparoscopic approach is safe and effective and led to resolution of symptoms. Further research is needed to better understand the development of PSNs, how suture technique at the time of C-section impacts the development of an isthmocele, and if one surgical approach leads to superior outcomes over another. ★ Best Gynecology Video

Objective: Pancreatic pseudocyst is a known complication of recurrent pancreatitis and requires intervention if symptomatic or complicated. Anterior cystogastrostomy has been well-described in surgical literature but data on a posterior laparoscopic/robotic approach are limited. Here we report a case of robotic cystogastrostomy and drainage of a pancreatic pseudocyst in a patient with a history of recurrent pancreatitis and compressive biliary obstruction. Methods and Procedures: In this video we demonstrate a posterior robotic approach to cystogastrostomy in a patient with a symptomatic pancreatic pseudocyst. Results: This is the case of a 43-year-old female with recurrent pancreatitis and resulting pancreatic pseudocyst. She presented with symptomatic biliary tract obstruction due to compression from the cyst. Gastroenterology evaluated the patient and determined her not to be a candidate for endoscopic ultrasound and stenting as they were concerned of proximity of the splenic artery. In this video, we visualize the posterior gastric wall and the retrogastric pseudocyst via the robotic approach, then proceed to open and drain the cyst. We utilize a stapler to create a cystogastrostomy and running sutures for closure. Conclusion: This video demonstrates the safety and efficacy of a posterior robotic approach to cytogastrostomy in patients with a retrogastric pancreatic pseudocyst. The posterior approach avoids the large anterior gastrostomy, provides more precise cyst visualization, and enables creation of a larger cystgastrostomy anastomosis as warranted.

Objective: Surgery on horseshoe kidneys is challenging due to complex anatomy, with over 75% having anomalous vasculature. Fewer than 300 cases of renal cell carcinoma (RCC) in horseshoe kidneys have been reported, with very few isolated to the isthmus. Using artificial intelligence (AI) software, a virtual segmented 3D kidney model was generated from triphasic CT imaging for preoperative planning and intraoperative navigation. We present a 65-year-old male with a 6-cm RCC at the isthmus of a horseshoe kidney and our approach to performing robotic-assisted heminephrectomy. Methods and Procedures: Robotic trocars were placed to left of the midline for transperitoneal access to the renal isthmus. The 3D model assisted in delineating the tumor and complex vasculature. Three renal arteries and 2 renal veins were identified and transected. Near-infrared fluorescence and intraoperative ultrasonography were used to define a margin between the mass and the left renal moiety. Right heminephrectomy and renorrhaphy was then performed. Results: Operative time was 5 hours 43 minutes. Estimated blood loss was 200 mL. Pathology revealed pT3aN0M0 clear cell RCC with negative margins. The patient had an uncomplicated postoperative course, and there was no evidence of disease at 6 months. Conclusion: Heminephrectomy of a horseshoe kidney with a renal mass located at the isthmus is technically challenging. Few reports of robotic-assisted partial nephrectomy for small isthmus-located RCCs have been published. To our knowledge, this is the first report describing the technique of robotic-assisted heminephrectomy for a large RCC located at the isthmus of a horseshoe kidney with the assistance of 3D anatomical modeling.

Background and Aims: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is technically complex with a challenging learning curve. Our aim was to create a low-cost, realistic, reproducible LRYGB model and validate its authenticity, effectiveness, and the learning curve for surgeons. Methods: 3D-printed intra-abdominal models were developed, and their physical properties were evaluated. A total of 16 surgeons (5 experts, 6 intermediates, 5 residents) assessed face validity, content validity, technical authenticity using questionnaires. Modified Bariatric Objective Structured Assessment of Technical Skills (MBOSATS) evaluated construct validity, and operation time was recorded to assess the learning curve. Results: The 3D models simulated human physical properties well. Compared to porcine models, they scored higher for aesthetics, size, and stomach shape ( P   .05). The 3 groups had significantly different MBOSATS scores and operation times ( P  < .01, P  < .001), indicating construct validity. With repeated training, the learning curve shortened significantly. Conclusions: These low-cost 3D-printed LRYGB models demonstrate realistic physical performance, serving as a substitute for porcine models. Simulated training enhances surgical skills and shortens the learning curve, potentially useful for future LRYGB training and assessment.

Objective: To compare the efficacy and safety of endoscopic combined intrarenal surgery with standard percutaneous nephrolithotomyin renal stones having medium to high S-ReSC score. Methods and Procedures: This study, which is nonrandomized, includes 62 patients who were admitted to the SZH Lahore urology department.Group B consisted of 31 patients who underwent sPCNL surgery while Group A consisted of 31 patients who underwent ECIRS surgery. χ 2 , t -test, and poststratification analysis were performed using SPSS version 25. Results: In the ECIRS group, 29.1% of patients had trouble making a puncture during surgery, compared to 51.6% in the sPCNLgroup.16.1% of ECIRS users had trouble establishing access, compared to 25.8% of sPCNL users. In the ECIRS group (9.7% vs 90.3%) and SPCNL group (6.5% vs 93.5%), the ReSCscores were medium and high, respectively. The incidence of pleural injuries was 6.5% in the ECIRS group and 25.8% in the sPCNL group. Operative time was greater in the sPCNL group (58.1% vs 16.1%) compared to the ECIRS group. Nephrostomy usage was 35.5% in the ECIRS group compared to 29.1% in the sPCNL group. DJ stent need in sPCNL compared to ECIRS (74.2% vs 51.6%). On one POD X Ray KUB and one month CT KUB, the residual stone free rate was 90.3% vs 83.9%) and 61.3% versus 48.4% in the sPCNL group, respectively, in the ECIRS group; 51.6% of group A had mild hematuria, while group B had 3.2% of severe hematuria; 93.5% of the sPCNLgroup had bleeding segmental vessels, compared to 0% in the ECIRS. Conclusions: When compared to standard percutaneous nephrolitholotomy for stones with a medium to high S-ReSC score, the study found that endoscopic combined intrarenal surgery yielded better results in terms of the number of tracts, iatrogenic damage, operational time, and stone-free rate.

Objective: This study aims to illustrate the diverse presentations of Meckel’s diverticulum (MD) in adults and the diagnostic challenges associated with it. Additionally, it seeks to demonstrate the approach to the laparoscopic management of a bleeding MD. Methods and Procedures: We present the case of a 19-year-old male with intermittent abdominal pain and hematochezia. Diagnostic workup included esophagogastroduodenoscopy, CT angiography, and colonoscopy, which were inconclusive. Technetium-99mm scan showed aberrant uptake, suggesting ectopic gastric mucosa, prompting exploratory laparoscopy, and terminal ileectomy with primary side-to-side anastomosis. Results: Despite negative imaging and atypical symptoms, a MD was identified intraoperatively, underscoring the diagnostic challenge in adults. Surgical intervention resulted in resolution of symptoms. Conclusion: Adult MD poses diagnostic dilemmas due to varied presentations and negative imaging. Clinicians should maintain a high index of suspicion, especially in cases of nonspecific symptoms, to prevent delays in diagnosis and reduce associated morbidity.

Objective: Vertical banded gastroplasty (VBG) is a historic form of bariatric surgery. A possible long-term complication is a stricture/obstruction related to the fixed gastric band. Endoscopic techniques can be successful in removal without surgery. Methods: A 70-year-old woman with history of VBG initially presented with refractory gastroesophageal reflux disease (GERD). Esophagogastroduodenoscopy (EGD) revealed severe reflux esophagitis and stricture in the proximal stomach caused by extrinsic compression. A 18 × 59 mm fully covered metal stent was deployed across the stricture under fluoroscopic guidance. Follow-up evaluation in 4 weeks noted gastric wall ulceration with eroding band into the luminal side. The stent was removed followed by removal of the gastric band that eroded completely using endoscopy. Results: Following band removal, stricture showed gastric wall ulceration without any perforation confirmed under fluoroscopy. Patient was discharged the same day tolerating diet and reported improved GERD. She was placed on high dose proton pump inhibitors. Follow-up EGD showed stricture at the site of gastric band removal and currently being managed with luminal stenting. Conclusion: Use of stents to induce erosion of the band into the lumen of the stomach is a safe way to prepare it for endoscopic removal. Stents aid in rapidly eroding the band by slow transmural necrosis, preventing free perforation. Removal is performed in a minimally invasive fashion, reducing complications and avoiding higher risk surgery. This remains possibly safer than surgical intervention when indicated. Recurrent stricture at the site of band removal could be a potential complication needing further endoscopic interventions.

Objective: Incisional hernias (IH) are a frequent complication following open surgery. While minimally invasive surgery (MIS) is designed to enhance patient recovery through smaller incisions, contemporary quantitative evidence supporting its efficacy in reducing IH rates is sparse. This study aims to provide an overview of IH rates comparing open and MIS abdominal. Methods and Procedures: Cochrane Central, Embase, and PubMed were searched for randomized controlled trials (RCTs) that compared open surgical approaches to MIS and reported incisional hernia incidence as a postoperative complication. RStudio Software was used for statistical analysis. Results: From the initial 9,425 results, 27 studies involving 6,052 patients were included, of which 3,309 (54.7%) underwent MIS. Analysis revealed a significantly lower incidence of IH among patients who received MIS (RR 0.56; 95%CI 0.38–0.82). Subgroup analysis by surgery type indicated that bariatric (RR 0.23; 95%CI 0.075–0.707) and fundoplication surgeries (RR 0.1; 95%CI 0.018–0.545) were associated with a substantial reduction in IH rates. Conversely, surgeries such as nephrectomy, cholecystectomy, colorectal, cystectomy, and gastrectomy did not show a significant difference. Conclusion: MIS is associated with a reduced incidence of IH in abdominal surgeries, particularly evident in bariatric and fundoplication procedures. These findings confirm the benefits of MIS in specific surgical contexts, highlighting its potential to decrease postoperative complications like IH. Further research focusing on comparing IH rates on open versus MIS approaches is warranted.

Introduction: Breast cancer stands as the most prevailing form of malignancy affecting women globally. 1–3 It is estimated that with continued globalization and economic growth, the incidence of breast cancer in developed countries will increase to 56% and in developing countries to 95% by the year 2040. 4 Breast cancer genes BRCA1 and BRCA2 are tumor suppressor genes whose mutations increase the lifetime risk of developing certain malignancies, particularly breast and ovarian cancer. 5–7 Data show that prophylactic mastectomies reduce the risk of breast cancer in BRCA2 mutation carriers by over 90%. 7 With the progression of laparoscopy being used in surgical oncology, this approach to mastectomies is gaining momentum and has been shown to improve postoperative recovery and decrease upper limb postoperative deficits. 8 The aim of this case report is to highlight the role of laparoscopic and endoscopic techniques in the setting of breast surgery. Methods and Procedures: This is a case report of a 42-year-old female with a family history of gynecologic cancers, diagnosed with BRCA2 gene mutation via genetic testing. A laparoscopic bilateral prophylactic mastectomy with simultaneous reconstruction using an endoprosthesis was performed with the goal of increasing patient comfort, and reducing scar size and overall invasiveness. Results: Histopathological examination revealed no malignancy. Patient discharged without further complications secondary to the procedure. Conclusions: Laparoscopic breast surgeries are technically challenging due a small working area, limited range of motion of instruments, and poor visibility. However, considering its benefits, it is an attractive alternative to traditional open mastectomies. 9 ★ Gustavo Stringel Award for Best Poster by a Student

Objective: The objective of this observational study is to demonstrate the safe use of abdominal wall elevation device with closed technique using Veress needle or direct entry with 3-mm port. Methods and Procedures: Female patients undergoing laparoscopic gynecologic procedure between July 2023 to May 2024 underwent preoperative screening ultrasounds to predict presence of obliterating adhesions. Abdominal wall elevation device was used during abdominal entry. Once entry confirmed major vascular, or visceral injury was assessed. Other events such as number of entry attempts, failed entry, and presence of adverse events during entry were noted. Descriptive statistics were used to characterize the patient population and incidence of abdominal entry injury or events. Results: Elevation device was used in 15 patients with Veress needle and 25 patients with 3 mm direct trocar. Abdominal entry was achieved via the umbilicus in 36 patients and left upper quadrant in 4 patients. There was no major vascular, visceral injury or failed entry events. Entry was achieved on first attempt in 35 patients. Of second attempt entries, one was with 3 mm trocar and 4 with Veress needle. Conclusion: Use of a device to elevate the abdominal wall in a standardized fashion is both safe and effective for laparoscopic abdominal entry. It can be used with its designed entry method of Veress needle and direct entry using 3 mm port.

Objective: The timely diagnosis and treatment management of colorectal cancer is of great importance for the oncologic results. A screening program and a national database for colorectal cancer in Bulgaria are not available. In the current study, a platform with access for scientific purposes to all national medical data was used to perform a nationwide analysis of colorectal cancer minimally invasive surgical treatment. Methods and Procedures: We analyzed data from January 2019 to May 2024 on a nationwide basis using an artificial intelligence (AI) powered software solution that has access to anonymized medical information through science-oriented hospital contracts. Information about colorectal cancer diagnosis, radical and palliative surgery procedures (open and minimally invasive) is analyzed and interpreted. An advanced SAP HANA in-memory database algorithms were used. Results: During the study period, the diagnosed patients with colorectal cancer (C18, C19, and C20—ICD) were 24,729. Surgical procedures were performed in 12,854 patients. Laparoscopic resections were done in 3,779 patients and robotic resections in 453 patients (a total of 4,232 minimally invasive resections—32.92%). Radical procedure was performed in 8184 patients (63.67%). Out of the 12,854 patients that underwent surgery, 2,877 were in IV stage (22.38%), 3,716 patients in III stage (28.91%), 3,929 patients in II stage (30.57%) and 2,332 patients in I stage (18.14%). Conclusion: In Bulgaria, the rate of minimally invasive radical surgery for colorectal cancer is still low and high rates of late-stage at the time of the diagnosis are observed. Colorectal screening program implementation is essential and needed.

Objective: To determine if there is any endometrial or myometrial cell spillage during minimally invasive hysterectomy with manual morcellation in a contained extraction system. Methods: Design: Prospective cohort study. Setting: University of Texas Medical Branch, an academic center. Patients: Patients undergoing laparoscopic or robotic hysterectomy for large fibroid uterus between August 2023 and April 2024. Intervention: Three peritoneal washings were collected at designated points in the surgery: First washing (W1) was collected once the peritoneal cavity was accessed laparoscopically second washing (W2) was collected after completion of hysterectomy, and third washing (W3) was collected “after” contained manual morcellation of the uterus. Three cytospin slides were prepared from each washing and stained with Romanowsky and Papanicolaou stains. Caldesmon IHC stain was used to confirm presence of smooth muscle cells if any was detected. If any washing was positive for myometrial cells, the number of cells was counted and reported per high power field (HPF). Methods: Design: Prospective cohort study. Setting: University of Texas Medical Branch, an academic center. Patients: Patients undergoing laparoscopic or robotic hysterectomy for large fibroid uterus between August 2023 and April 2024. Intervention: Three peritoneal washings were collected at designated points in the surgery: First washing (W1) was collected once the peritoneal cavity was accessed laparoscopically second washing (W2) was collected after completion of hysterectomy, and third washing (W3) was collected “after” contained manual morcellation of the uterus. Three cytospin slides were prepared from each washing and stained with Romanowsky and Papanicolaou stains. Caldesmon IHC stain was used to confirm presence of smooth muscle cells if any was detected. If any washing was positive for myometrial cells, the number of cells was counted and reported per high power field (HPF). Results: Twenty-five patients were included in the analysis. The median age was 43.5 years (range, 28–52), the median weight of the uterus was 388 g (range, 191–831). Contained manual morcellation was done transvaginally in 22 subjects (88%), and transabdominally through a mini laparotomy incision in 3 subjects (12%). Two subjects (8%) had myometrial cell spillage detected in the peritoneal washings. The first case; spillage was detected only in W2, spilled cells count was 10–20 cells/HPF, morcellation was done transvaginally and uterus weighed 464 g. The second case; spillage was detected only in W3, spilled cells count was 10–20 cells/HPF, morcellation was done transvaginally and uterus weighed 242 g. Conclusion: Contained manual morcellation of large fibroid uterus appears to be effective technique to minimize tissue dissemination during minimally invasive hysterectomy; however, spillage still can occur before morcellation from manipulation of the large uterus.

Objective: Latrogenic ureteral injury is a surgical complication causing severe morbidity for patients. Surgeons performing minimally invasive operations in the abdominopelvic cavity must recognize anatomical variations to avoid injury. We report our experience using pre- and intraoperative strategies to avoid ureteral injury during a robotic hemicolectomy for a patient with variations in abdominopelvic anatomy. Methods and Procedures: A 56-year-old male was found to have a 10-mm sessile polyp consistent with well-differentiated neuroendocrine tumor and dilated collecting system on imaging. During ureteral catheter placement, torturous, obstructed ureter was found. Extensive lysis of adhesions was required due to previously undetected intestinal malrotation. Results: Manipulation of the duplicated ureter around structures such as the inferior vena cava and ascending colon prolonged the expected operative time. The specimen obtained was a primary malignant neuroendocrine tumor of the small intestine. Injection of indocyanine green and dissection of the ureters allowed the urologist to avoid injury to the retrocaval ureter. The use of landmarks and robotic approach enabled the surgical oncologist to resect the specimen without complications in a patient with multiple anatomic variations. Conclusion: Previous studies have found decreased odds of IUI with the minimally invasive approach vs open cases and particularly robotic surgery vs open cases. Our report lends support to the practice of identifying which patients are at high-risk for IUI and using a robotic approach in abdominopelvic surgery. Clearer guidelines are needed to select which patients are at need for these interventions.

Objective: The study purpose was to evaluate the success and safety of same day discharge (SDD) following minimally invasive hysterectomy and myomectomy at a safety net hospital. While there is ample evidence for the safety of SDD, there is less literature on its success in underserved populations. A quality improvement project was conducted at an academic safety net hospital in which the population is 50% Spanish-speaking, 66% Latinx, 70% have public insurance, and 25% are uninsured. Methods and Procedures: Patients undergoing hysterectomy or myomectomy from June 2020 to February 2022 were included. Preoperatively, patients were counseled about discharge, safe housing/transportation were ensured, and comorbidities were addressed. Intraoperatively, medications were given to minimize nausea and pain. Postoperatively, the surgeon performed a telephone visit the day after. Results: A total of 185 patients underwent surgery. Previous to June 2020, 100% of these patients were admitted for overnight stay. SDD success in June 2020 was 63% (5/8) with gradual increases over time. SDD success maintained an average of >95% from August 2021 to February 2022. Postoperative day 1 phone calls per month ranged from 67% to 100%. During the 22-month duration of the project, the overall SDD success rate was 77% (143/185); 92% (132/143) had postoperative telephone visits, and only one patient (0.54%) was readmitted. Conclusion: There is limited data on the details of SDD protocols at safety-net hospitals. This QI project demonstrates that SDD is possible and safe in this environment. Future practices will need to assess social determinants of health that affect recovery and SDD success. ★ Best Gynecology Scientific Paper

Objective: Laparoscopic cholecystectomy has remained the gold standard approach of gallbladder surgery for nearly 2 decades. However, adoption of robotics for treatment of gallbladder disease continues to grow. Despite this growth, clinical outcomes regarding laparoscopic versus robotic cholecystectomy remain unclear. Methods: We conducted a multihospital retrospective cohort study of patients who underwent cholecystectomy between August 1, 2021 and November 30, 2023. We compared demographic and clinical characteristics, surgical details, and postoperative outcomes between laparoscopic and robotic groups. The postoperative outcomes analyzed included conversion to open, bile leak, major duct injury, return to operating room, surgical site infection, blood transfusion, readmission, and death. Statistical analysis included χ 2 tests, t -tests, Wilcoxon rank sum tests, and multivariable logistic regression. Results: A total of 4,316 patients were included (3,736 laparoscopic, 580 robotic). Robotic surgery was associated with lower rates of conversion to open ( P  = .019) and bleeding requiring transfusion ( P  = .017). We also saw trends towards statistical significance for bile leaks, major duct injuries, surgical site infections, and 30-day return to operating room. Robotic approach was associated with a 5 minute longer average surgery time ( P  = .002). Using multivariable logistic regression analysis to account for preoperative differences between the 2 groups, robotic surgery was associated with a 62% decreased risk of any complication (OR = 0.38, 95% CI [0.20, 0.74]). Conclusion: Robotic cholecystectomy demonstrates favorable clinical outcomes compared to laparoscopic cholecystectomy. These findings support the advantages of robotic assistance during cholecystectomy. To our knowledge, this represents one of the largest retrospective studies showing a clinical benefit from the robotic approach.

Objective: In pelvic surgery, a minimally invasive approach provides a multitude of benefits compared to open surgery. The surgical skills required for laparoscopic surgery are unique, requiring enhanced hand-eye coordination to safely operate using 2-dimension visual images. Surgical training thus must balance patient safety while ensuring that surgeons reach appropriate proficiency levels. To achieve this aim, simulation has been widely utilized to provide laparoscopic skills training. Box trainers have been shown to be effective in acquiring basic laparoscopic skills and have additionally shown benefit in reducing operative time and risk of perioperative complication. However, surgical trainers can be cost-prohibitive in resource-limited areas and are not consistently available across all training centers. The objectives of this video are to demonstrate construction of 2 low-cost laparoscopic box trainers and show application of the trainer to practice the fundamentals of laparoscopic surgery (FLS) practical examination tasks. Methods and Procedures: Both laparoscopic box trainer designs were created by author MT and their construction and application have been documented to improve access to low-cost laparoscopic training devices. Results: No data collection was involved in the creation of this surgical education video. Conclusion: This technique may be used and modified by surgical trainees for home use or in low-resource settings to improve access to laparoscopic skills simulation, thus improving trainee comfort with laparoscopy.

Objective: To identify the area of research which may simplify the hisopathological correlates and biomarkers which may signify endometriosis rather than continue looking for “typical endometriosis” in histopathological specimens obtained during surgery. Methods and Procedures: A retrospective study of cases of endometriosis diagnosed at laparoscopy during the past 5 years, from the author's data will be presented. OR findings of endometriotic lesions or indirect evidence thereof (like de novo adhesions) will be discussed along with Pathological Correlation- at a tertiary care hospital in New York. The common biomarkers which indicate endometrial stroma and epithelial markers where “atypical endometriosis” or occult microscopic endometriosis (OME) is suspected and their results as compared to clinical/visual presentation will be reviewed. Results: In the author's data there is approximately 40% correlation and 60% discordance between clinical and pathological findings. Conclusion: A need for a deeper investigative histological methods is required in this enigmatic disease known as endometriosis. The clinical-histological grading currently in use is getting outdated rapidly as tissue biomarkers become available and a demand for definitive diagnosis of “atypical endometriosis” and OME are on the uprise. Research in this field is imperative and a concomitant education of pathologists and clinicians is necessary to treat patients effectively.

Background: Minimally invasive gynecologic surgery (MIGS) is a quickly developing subspecialty of obstetrics and gynecology. Consistent surgical consultations and referrals remain critical for multiple stakeholders including patients and their outcomes, physicians, and hospitals. The objective of this study is to provide a description of common MIGS subspecialist practices in that of a large, midwest urban tertiary care network. Methods: This is a retrospective chart review from August 2022 to June 2023. All patients under the care of a MIGS subspecialist within an urban tertiary care network were included in this study. Results: A total of 426 patients were seen in the MIGS department. Of those, 25% of these patients (n = 107) were referred specifically for consultation and eventually underwent surgery for benign gynecologic pathology; 2% of patients (n = 9) were seen within the MIGS division for obstetrical care, either as a new patient or for ongoing antenatal care; 4% of patients (n = 18) were seen in the office for a well woman’s examination. 68% of patients (n = 292) presented to the office for a problem-focused visit that was gynecologic in origin but did not require surgical consultation. Conclusion: Within a large urban referral network, surgical consultations made up a total of 25% of patients seen in a daily office day amongst MIGS subspecialists. In order to better utilize MIGS subspecialists for optimum surgical care, ease of routine physician schedules, as well as maximized hospital utilization of surgical subspecialists, a referral pattern would be reasonable to help patients seeking the appropriate level of care for their gynecological surgical needs.

Objective: Minimally invasive surgery (MIS) has underscored the consequences of conversion to open colectomies. We performed a systematic review and meta-analysis assessing the impact of conversion during MIS colectomy. Methods and Procedures: PubMED, Cochrane, Scopus, and SciELO were searched for studies analyzing conversion during MIS colorectal resections. Outcomes were readmission, surgical site infections (SSI), blood loss, postoperative complications, transfusion, cancer recurrence, 30-day mortality, 5-year cancer-free survival rate, 5-year overall survival rate, operative time, ileus, bleeding, and leak. Results: A total of 5,407 studies were screened, and 45 were included, comprising 499,519 patients, from which 68,638 (13.74%) underwent conversion. Converting increases postoperative complications (RR 2.2; 95% CI 1.76, 2.75; P  < .001), readmission (RR 1.54; 95% CI 1.44, 1.66; P  < .001), transfusion (RR 2.73; 95% CI 2.41, 3.08; P  < .001), leak (RR 1.75; 95% CI 1.53, 2.01; P  < .001), ileus (RR 2.26; 95% CI 1.64, 3.12; P  < .001), SSI (RR 2.58; 95% CI 2.1, 3; P  < .001), and recurrence (RR 1.57; 95% CI 1.24, 1.98; P  < .001). Conversion had greater blood loss (MD 196.7 mL; 95% CI 117.4, 275.2; P  < .001), longer operative time (MD 27 min; 95% CI 17.7, 36.3; P  < .001), higher 30-day mortality (RR 3.26; 95% CI 1.5, 7; P  = .003), longer time to flatus (MD 0.8 day; 95% CI 0.52, 1; P  < .001), and lower 5-year overall survival (RR 0.85; 95% CI 0.76, 0.94; P  = .002) and 5-year disease-free survival (RR 0.78; 95% CI 0.65, 0.95; P  = .012). Subgroup analyses showed similar results for malignant and benign diseases. Conclusion: Converting is associated with increased perioperative complications during MIS colectomy for both malignant and benign colorectal diseases.

Objective: Vaginal endometriosis is an underreported form of deeply infiltrating endometriosis which is rarely located anteriorly. This video demonstrates a laparoscopic approach to extensive, severely symptomatic deep infiltrating anterior vaginal endometriosis. Methods and Procedures: Case report of rare case of anterior deep infiltrating vaginal endometriosis. Results: Laparoscopic excision of deep infiltrating anterior vaginal endometriosis by laparoscopic approach with amelioration of symptoms and successful pregnancy. Conclusion: Anterior deep infiltrating endometriosis is rare with symptoms that can include severe dyspareunia, dyschezia, and dysmenorrhea. Massive vaginal bleeding can occur. Laparoscopic resection aided by vaginal palpation is able to remove the disease and resolve symptoms. Preservation of the uterus and pregnancy is possible. There is limited data on option of vaginal delivery.

Objective: Postoperative atrial fibrillation (POAF) is a common complication following pulmonary lobectomy, with potential adverse effects on patient outcomes. Identifying predictors of POAF could aid in risk stratification and preventive strategies. Resting heart rate (RHR) has been suggested, as a potential predictor of POAF in pulmonary lobectomy patients. This study aimed to investigate the association between RHR and development of POAF in patients undergoing robotic-assisted pulmonary lobectomy (RAPL). Methods and Procedures: Analysis was conducted on 719 lobectomy patients, with 188 excluded for prior history of arrythmias, leaving 531 in the final cohort. RHR was measured during preoperative evaluation prior to RAPL. Patients were monitored postoperatively for occurrence of POAF. Results: Among the study cohort, 95 patients (17.9%) developed POAF following RAPL. The non-POAF mean was calculated as 73.8 ± 0.6 (SEM) bpm, and the POAF sample mean as 75.9 ± 1.3 (SEM) bpm. A single sample z-score of 1.71 was calculated for the POAF population, with a P value of .046 ( P  < .05), which is statistically significant. The sensitivity of a RHR greater than 89.5 bpm was found to be 15.8%, and the specificity was 89.2%. For Patients with RHR above 89.5 bpm (n = 62), the risk of POAF increased by greater than 50% (odds ratio = 1.55), with 24.2% developing POAF. Conclusion: These findings suggest that RHR along with other factors may serve as a valuable tool for early identification of individuals at higher risk of developing POAF. However, further research is needed to explore potential interventions for reduction of POAF in this population.

Objective: To demonstrate the surgical technique of an intact cystectomy of a large dermoid ovarian cyst. Methods and Procedures: This is a case of a 32-year-old G2P1011 with intermittent right sided pelvic pain who was found to have an 11-cm right ovarian dermoid cyst on MRI. Laparoscopic right ovarian cystectomy was performed with the following video footage illustrating the surgical steps with narrated description. Results: A pathologically confirmed ovarian dermoid cyst was enucleated intact and subsequently decompressed in an endocatch bag. Given the characteristic viscous, sticky material within dermoid tumors, cyst rupture can make a successful cystectomy increasingly challenging. We identified key steps to facilitate an intact cystectomy by avoiding unintentional cyst rupture: Create a longitudinal incision along the antimesenteric axis of the mass Identify the plane between the cyst wall and ovarian cortex Extend initial longitudinal incision along the full length of the cyst Minimal use of direct traction on the thinned ovarian cortex Alternating blunt and sharp dissection with use of a laparoscopic rolling technique Judicious use of thermal energy to minimize damage to ovarian follicles and preserve reproductive potential Use of bipolar energy near vascular ovarian hilum to minimize blood loss and release cyst intact Create a longitudinal incision along the antimesenteric axis of the mass Identify the plane between the cyst wall and ovarian cortex Extend initial longitudinal incision along the full length of the cyst Minimal use of direct traction on the thinned ovarian cortex Alternating blunt and sharp dissection with use of a laparoscopic rolling technique Judicious use of thermal energy to minimize damage to ovarian follicles and preserve reproductive potential Use of bipolar energy near vascular ovarian hilum to minimize blood loss and release cyst intact Conclusion: Laparoscopic cystectomy of large dermoid cysts is safe and feasible. While this may become more challenging in the setting of cyst rupture, following a systematic approach with these key steps can facilitate intact enucleation in a reproducible fashion.

Objective: To review and assess the current literature within the past 10 years on the use of native tissue repairs (NTR) versus mesh for anterior compartment defects and provide evidence-based recommendations on safety and durability derived from recent data analysis. Methods: A PubMed keyword search was conducted using [native tissue repair] and [mesh] and [pelvic organ prolapse] from 2003 to 2024 including non-English language publications. Results: The keyword search yielded 248 publications of which the most recent, ie, studies conducted within the last 10 years were included in the literature review. Of the 218 most recent studies, based on investigator (I.M.V.) discretion as to clinical relevance and significance, 15 were included in the final analysis for presentation. Conclusion: Since the 2019 FDA ban on the sale and distribution of surgical mesh for the treatment of anterior compartment prolapse, there has been a resurgence in interest in NTR as an alternative approach. Although many of the surgical techniques such as SSLF-Richter have been previously described, their long-term anatomical and functional outcomes are still somewhat unknown and therefore, further studies are required to assess their suitability and efficacy in the treatment of pelvic organ prolapse (POP).

Background: Laparoscopic retromuscular inguinal repair (LRMIR) is an ideal site to place the mesh on the inner bone surface of the abdominal muscle. Mobilization of fascia transversalis maybe causes bleeding. Retro-muscular local anesthesia technique (RLAT) was used successfully in laparoscopic sleeve gastrectomy and in place laparoscopic placement peritoneal dialysis catheter encouraging to modify the technique in LRMIR aiming, local anesthesia and aid in creating retro muscular plane assessing the outcome of pain and recurrence. Methods/Technique: Seventy patients were involved in this study from January 2016 to January 2023. RLAT was used in LRMIR for all patients. A 2 mg/kg bupivacaine with 0.1 ml norepinephrine was diluted in 250 ml saline and injected retro rectal spaced distal to umbilical up to pubic bone and second site from the anterior superior iliac spine to the edge of posterior rectal sheath infraumbilically. The peritoneum including fascia transversalis cut with secured haemostasis up to the pubic rami identifying rectus abdominis, transverse abdominis, psous major, and pubic rami 15 × 15 cm mesh was applied to cover the hernial defect. All were discharged same day. Results: No wound infection occurred. One patient has pain and needs to be treated in a pain clinic. No recurrence was encountered during the follow-up. Five patients were treated by local anesthesia only. The procedure was done as day surgery. One patient has had pain for 3 months. Conclusion: RLAT is a valuable, practical, and easy technique in LRMIR, helping to create an ideal retro muscular plane in placing 15 × 15 cm mesh in managing inguinal and femoral hernia.

Objective: Most surgeons use 1 10- to 12-mm and 2 5-mm trocars for laparoscopic appendectomy (LA). It would be desirable to further miniaturize LA. Methods and Procedures: Sixty-five consecutive appendectomies were divided into 5 subgroups: group 1 (n = 12) and 2 (n = 15) were done with 2 5-mm ports and a needle grasper or suture passer, group 3 (n = 11) using 3 5-mm ports, group 4 (n = 19) and using 1 10- to 12- and 2 5-mm ports; group 5 (n = 8) included miscellaneous cases. Left upper quadrant and umbilical 5-mm ports were placed and after exploration it was decided, which technique was most appropriate. The appendix was secured with an endoloop in groups 1, 2, 3 and a stapler in group 4. Results: Patients in groups 1 and 2 were younger (median 26.1/16.9 years vs 33.4/28.2 years for groups 3 and 4), had a lower BMI (median 25.5/25.9 vs 26.9/30.9 kg/m 2 for groups 3 and 4) and had the shortest OR times (median 30.5/36 minutes vs 42/35 minutes for groups 3 and 4); 79% of children were in groups 1 and 2. In group 4 significantly more patients had gangrenous or perforated appendicitis. There were no stump leaks and no differences in complication rates between the groups were found. Group 5 included combined procedures including hernia repair (1), cholecystectomy (2), Meckel diverticulum resection (2), abdominal exploration with biopsies (2), and small bowel resection (1). Conclusion: With our approach, 64% of patients did not require a large (12 mm) port and in one third only 2 5-mm ports were used and excellent outcome and high patient satisfaction was achieved. ★ Best General Surgery Scientific Paper

Objective: In 2026, the New European Surgical Academy established Europe’s first “Natural Orifice Surgery” working group. Comprising leading surgeons across diverse disciplines, the group’s primary aim was to advance the development of scarless surgical procedures and to follow the various stages of progress, alongside the challenges. Methods and Procedures: Anatomical and preclinical studies evaluating the feasibility of Trans Douglas and Trans Oral operations were conducted at the University Hospital of Rotterdam. The findings indicated that the Douglas Pouch in women allows for the utilization of instruments up to 25 mm in diameter without causing any damage. The sublingual approach to the Thyroid was successfully demonstrated with minimal complications. Initial clinical studies were undertaken, with Trans-Douglas surgeries performed as hybrid operations due to the unavailability of designed instruments, while transoral thyroidectomy is already widely employed through endoscopy or robotics. Results: Over 400 hybrid Trans-Douglas cholecystectomies have already been conducted, with a conversion rate to endoscopy of less than 1%. The method proves as successful as conventional endoscopic cholecystectomy, potentially becoming a routine for women. Over 350 publications from various countries exist on transoral thyroidectomy, highlighting complications such as CO 2 embolism, transient perioral numbness, hypoparathyroidism, and vocal cord palsy. While designed instruments are still necessary, this approach is feasible and comparable to conventional procedures in highly selected patients. Conclusion: The realm of scarless operations, or natural orifice surgeries, holds great promise. However, the realization of safe and efficient procedures for patients necessitates the development of surgical simulators and designed instruments.

Objective: Large elements uterine myomatosis is considered to be a uterus larger than 250 g. Robotic hysterectomy is presented as an advanced surgical option for the treatment of this condition. Through video, analyze the approach to a 24-week large element myomatosis with a robotic surgical system, highlight its safety and effectiveness, reduction in blood loss and faster recovery. Methods and Procedures: This is a descriptive video of the surgical strategy for a complicated hysterectomy of a 24-week size uterus with a robotic surgical platform. We summarize the 24-week robotic hysterectomy for myomatosis in 7 steps: Palmer’s incision point is the technique to introduce optical lens and plan surgery under these conditions. Abdominal incisions to introduce trocars are adapted to the patient in this particular scenario. Liberation of adhesions that obstruct visibility of the optical lens. Docking of the robotic arms. Dissection, sealing, cutting of round ligaments, opening of broad ligaments, uterine arteries, colpectomy, and infundibulopelvics ligaments. The vaginal cuff is closed with barbed sutures. Minilaparotomy of 6 cm was use for a surgical piece extraction. Palmer’s incision point is the technique to introduce optical lens and plan surgery under these conditions. Abdominal incisions to introduce trocars are adapted to the patient in this particular scenario. Liberation of adhesions that obstruct visibility of the optical lens. Docking of the robotic arms. Dissection, sealing, cutting of round ligaments, opening of broad ligaments, uterine arteries, colpectomy, and infundibulopelvics ligaments. The vaginal cuff is closed with barbed sutures. Minilaparotomy of 6 cm was use for a surgical piece extraction. Results: This is the largest myomatosis recorded with this robotic system so far. Piece: 1,391 g, blood loss: 125 cc. Conclusion: Robot-assisted laparoscopic hysterectomy is a safest and effective option for the treatment of large uterine fibroids, minimizing blood loss and improving precision in surgical dissections. The patient benefits of a fast recovery.

Objective: Management of bariatric surgery emergency; perforated marginal ulcer by robotic-assisted surgery. Methods and Procedures: Robotic-assisted repair of perforated marginal ulcer. Results: Bariatric and gastric surgical emergency remain challenging due to the need of intracorporeal suturing, this can be challenging due to the body habitus and suboptimal exposure as a result of the location and complexity of the disease in certain cases. We present a case of a 39-year-old female who underwent a robotic modified Graham’s patch repair of a perforated marginal ulcer. Conclusion: Robotic surgery for bariatric emergency is feasible and can result in superior outcome and may decrease the conversion rate to open surgery.

Objective: Anti-NMDA receptor encephalitis is an autoimmune encephalitis with antibodies to NR1 or NR2 subunits of the NMDA receptor. It is commonly associated with ovarian teratomas which are present in 44% of female cases. The objective of this video is to demonstrate the critical role of the gynecologic surgeon in the treatment of anti-NMDA receptor encephalitis. Methods and Procedures: A 29-year-old female with anti-NMDA receptor encephalitis is presented. She was transferred to a tertiary care center after presenting with psychosis, altered mental status, and seizures. Pelvic imaging revealed the presence of an adnexal cystic lesion and so ovarian teratoma-related anti-NMDAR encephalitis was suspected. Results: The patient underwent laparoscopic unilateral sapling-oophorectomy. Following surgery, neuropsychiatric symptoms improved although postoperative course was initially complicated by factors related to the critical progression of the disease prior to surgery. She went on to make a full recovery to cognitive baseline and was discharged to inpatient rehab on hospital day 46. Conclusion: Surgical removal of ovarian teratoma if present in patients with anti-NMDA receptor encephalitis is crucial to treatment. Studies suggest that early surgical intervention significantly improves neuropsychiatric symptoms, decreases recurrence, and is associated with more frequent complete recovery.