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446 Totally Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Mucinous Adneocarcinoma of the Appendix
442 Difficult Diverticulits and Failed Anastomosis: Troubles and More Troubles Barry Salky This is a 68 year old female with mulitiple episodes of diverticulitis documented on CT scans. Dyspareunia is a recent symptom. This video demonstates several technical challenges assoiciated with chronic diverticulitis. After completion of the descending rectal anastomosis, a leak was detected and the video demostrates one technique of recovery in a difficult clinical situation. 443 Laparoscopic Repair of a Large Right Sided Morgagni's Hernia David Lawrence, Yuhsin V. Wu, Michael J. Rosen Morgagni's hernias are rare congenital anterior diaphragmatic hernias for which the optimal method of repair is unknown. This video presents a morbidly obese patient with oxygen dependent chronic obstructive pulmonary disease and a Morgagni's hernia that compresses her entire right lung. Omentum and colon are seen herniating through the 10x15cm defect. Through a laparoscopic approach the intra-abdominal contents were reduced, the defect primarily closed, and re-enforced with mesh. After the repair, the patient had significant improvements in pulmonary status. Laparoscopic repair with mesh re-enforcement is a viable and easily accomplished approach for Morgagni's hernia repair.
Figure 1: Decision Tree 437 Robotic Assisted Median Arcuate Ligament Release Martin J. Dib, Mark P. Callery, Marc Schermerhorn, A. James Moser 40-year-old female with chronic abdominal pain and preoperative aortography consistent with median arcuate ligament syndrome. Ports and a laparoscopic liver retractor are placed. After docking the robot, the left gastric vein is divided. The left gastric artery is encircled with a vessel loop to apply inferior traction and identify the common hepatic artery of the celiac trunk. The left lateral border of the celiac trunk is dissected. Hook cautery and LigaSure is used to divide the left crus of the diaphragm. Finally, circumferential skeletonization of the aorta at the entrance of the celiac trunk is achieved.
445 Modern Chemotherapy Mitigates Adverse Prognostic Effect of Regional Nodal Metastases in Stage IV Colorectal Cancer Yun Shin Chun, Steven Cohen, John H. Donohue, Barbara Burtness, Michael J. Hall, David M. Nagorney Background: In colorectal cancer, the involvement of regional lymph nodes with metastasis is an established prognostic factor. However, the impact of the number of positive regional nodes on patient outcome with stage IV disease is not well-defined. Methods: A retrospective review was performed of 869 patients at two tertiary referral centers with synchronous stage IV colorectal cancer who underwent resection of their primary tumors. Associations between number of positive regional lymph nodes stratified by the 7th edition AJCC staging system, lymph node ratio (LNR), and overall survival (OS) from date of diagnosis were analyzed. Median follow-up was 19 months (range, 1-211 months). Results: The number of positive regional nodes and LNR correlated with the presence of multiple sites of distant metastases (p,0.001). Survival was significantly associated with number of positive nodes and LNR, with median OS of 36 months with negative regional nodes, compared to 17 months with ./= 7 positive nodes (p ,0.001). Among 315 patients treated with modern oxaliplatinor irinotecan-based chemotherapy after colorectal resection, survival was not significantly associated with number of positive regional nodes (p=0.072) or LNR (p=0.34). The number of regional nodal metastases correlated with OS among 249 patients who underwent resection of liver metastases but lost prognostic significance in the subset of 105 patients who underwent hepatectomy with perioperative modern chemotherapy. Conclusions: In stage IV colorectal cancer, increasing number of positive regional lymph nodes and LNR correlate with multiple sites of distant metastases and poorer survival. The number of metastatic regional lymph nodes loses prognostic significance with modern chemotherapy, particularly in patients undergoing resection of liver metastases.
438 Enucleation of Hepatic Neuroendocrine Tumor Metastases Nicholas N. Nissen, Vijay G. Menon Neuroendocrine tumors (NET) represent a unique type of hepatic metastasis. These tumors tend to be well encapsulated and generally carry a favorable prognosis. Many of these patients will require repeated hepatic interventions over a period of several decades. Surgical enucleation of hepatic NETs is a technique that is not often employed but that holds great potential for preservation of maximal hepatic parenchyma, while carrying a low risk of injury to underlying vascular and biliary structures. This video describes the application of enucleation to patients with NET metastases and addresses patient selection, surgical techniques and management of complications.
SSAT Abstracts
439 Endoscopic Removal of a Laparoscopic Adjustable Gastric Band That Is Eroded Aurora D. Pryor, Dana A. Telem, Joshua Karas, Georgios Spentzouris, Eleanor Fallon, Jonathan Buscaglia This is a case of a 52-year-old male with history of morbid obesity status-post Laparoscopic Band at an outside hospital complicated by port infection and band erosion. Following port removal, the patient presented for removal of the laparoscopic band. Due to the extent of the intra-gastric band erosion, total endoscopic removal was attempted succesfully. This case highlights the mechanism of endoscopic removal of the band, challenges encountered, and techniques to navigate these obstacles. The patient tolerated removal of the band, was started on a liquid diet immediately, and was discharged on post-operative day one. 440 Totally Laparoscopic Left Colonic Resection With Intracorporeal Anastomosis Laura Doyon, Celia M. Divino, Scott Q. Nguyen, Edward Chin This video demonstrates two complementary laparoscopic cases, each focusing on techniques for intracorporeal anastomosis. The first is an elective sigmoid resection for history of uncomplicated diverticulitis. It uses an end-to-side intracorporeal anastomosis performed with a circular stapler. The second is a left hemicolectomy, performed for descending colon cancer. It employs a side-to-side intracorporeal anastomosis performed with a linear stapler and sewn common enterotomy. Totally laparoscopic colonic resection with intracorporeal anastomosis can facilitate resection in obese patients, as well as improve cosmesis and wound complications by reducing incision length for extraction.
446 Totally Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Mucinous Adneocarcinoma of the Appendix Cherif Boutros, Nader Hanna
441
Open cytoreductive Surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) has emerged as the procedure of choice for mucinous adenocarcinoma of the appendix (MAA), however is associated with substantial morbidity. We present a case of a totally laparoscopic R0- CRS-HIPEC for MAA. CRS included: right hemicolectomy, omentectomy, cholecystectomy, bilateral salpingo-oopherectomy, excision of the round and falciform ligaments and stripping of the peritoneum of the right diaphragm; followed by HIPEC through single inflow and outflow catheters. OR time was 380 mns and EBL was 100 mL. There was no postoperative morbidity. The patient was discharged home on postoperative day 8.
Laparoscopic Central Pancreatectomy and Pancreaticogastrostomy for the Management of a Proximally Migrated Pancreatic Stent Marc G. Mesleh, Frank Lukens, Michael B. Wallace, Horacio J. Asbun, John Stauffer A 43 year old female had a pancreatic stent placed during ERCP for elevated LFTs. The stent migrated proximally into the pancreas and was unable to be retrieved with multiple endoscopic attempts. After several episodes of pancreatitis, she was evaluated for surgical retrieval. A laparoscopic central pancreatectomy was performed to remove the stent, and a pancreaticogastrostomy was created for reconstruction.
SSAT Abstracts
S-1048
Figure 1: Decision Tree 437 Robotic Assisted Median Arcuate Ligament Release Martin J. Dib, Mark P. Callery, Marc Schermerhorn, A. James Moser 40-year-old female with chronic abdominal pain and preoperative aortography consistent with median arcuate ligament syndrome. Ports and a laparoscopic liver retractor are placed. After docking the robot, the left gastric vein is divided. The left gastric artery is encircled with a vessel loop to apply inferior traction and identify the common hepatic artery of the celiac trunk. The left lateral border of the celiac trunk is dissected. Hook cautery and LigaSure is used to divide the left crus of the diaphragm. Finally, circumferential skeletonization of the aorta at the entrance of the celiac trunk is achieved.
445 Modern Chemotherapy Mitigates Adverse Prognostic Effect of Regional Nodal Metastases in Stage IV Colorectal Cancer Yun Shin Chun, Steven Cohen, John H. Donohue, Barbara Burtness, Michael J. Hall, David M. Nagorney Background: In colorectal cancer, the involvement of regional lymph nodes with metastasis is an established prognostic factor. However, the impact of the number of positive regional nodes on patient outcome with stage IV disease is not well-defined. Methods: A retrospective review was performed of 869 patients at two tertiary referral centers with synchronous stage IV colorectal cancer who underwent resection of their primary tumors. Associations between number of positive regional lymph nodes stratified by the 7th edition AJCC staging system, lymph node ratio (LNR), and overall survival (OS) from date of diagnosis were analyzed. Median follow-up was 19 months (range, 1-211 months). Results: The number of positive regional nodes and LNR correlated with the presence of multiple sites of distant metastases (p,0.001). Survival was significantly associated with number of positive nodes and LNR, with median OS of 36 months with negative regional nodes, compared to 17 months with ./= 7 positive nodes (p ,0.001). Among 315 patients treated with modern oxaliplatinor irinotecan-based chemotherapy after colorectal resection, survival was not significantly associated with number of positive regional nodes (p=0.072) or LNR (p=0.34). The number of regional nodal metastases correlated with OS among 249 patients who underwent resection of liver metastases but lost prognostic significance in the subset of 105 patients who underwent hepatectomy with perioperative modern chemotherapy. Conclusions: In stage IV colorectal cancer, increasing number of positive regional lymph nodes and LNR correlate with multiple sites of distant metastases and poorer survival. The number of metastatic regional lymph nodes loses prognostic significance with modern chemotherapy, particularly in patients undergoing resection of liver metastases.
438 Enucleation of Hepatic Neuroendocrine Tumor Metastases Nicholas N. Nissen, Vijay G. Menon Neuroendocrine tumors (NET) represent a unique type of hepatic metastasis. These tumors tend to be well encapsulated and generally carry a favorable prognosis. Many of these patients will require repeated hepatic interventions over a period of several decades. Surgical enucleation of hepatic NETs is a technique that is not often employed but that holds great potential for preservation of maximal hepatic parenchyma, while carrying a low risk of injury to underlying vascular and biliary structures. This video describes the application of enucleation to patients with NET metastases and addresses patient selection, surgical techniques and management of complications.
SSAT Abstracts
439 Endoscopic Removal of a Laparoscopic Adjustable Gastric Band That Is Eroded Aurora D. Pryor, Dana A. Telem, Joshua Karas, Georgios Spentzouris, Eleanor Fallon, Jonathan Buscaglia This is a case of a 52-year-old male with history of morbid obesity status-post Laparoscopic Band at an outside hospital complicated by port infection and band erosion. Following port removal, the patient presented for removal of the laparoscopic band. Due to the extent of the intra-gastric band erosion, total endoscopic removal was attempted succesfully. This case highlights the mechanism of endoscopic removal of the band, challenges encountered, and techniques to navigate these obstacles. The patient tolerated removal of the band, was started on a liquid diet immediately, and was discharged on post-operative day one. 440 Totally Laparoscopic Left Colonic Resection With Intracorporeal Anastomosis Laura Doyon, Celia M. Divino, Scott Q. Nguyen, Edward Chin This video demonstrates two complementary laparoscopic cases, each focusing on techniques for intracorporeal anastomosis. The first is an elective sigmoid resection for history of uncomplicated diverticulitis. It uses an end-to-side intracorporeal anastomosis performed with a circular stapler. The second is a left hemicolectomy, performed for descending colon cancer. It employs a side-to-side intracorporeal anastomosis performed with a linear stapler and sewn common enterotomy. Totally laparoscopic colonic resection with intracorporeal anastomosis can facilitate resection in obese patients, as well as improve cosmesis and wound complications by reducing incision length for extraction.
446 Totally Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Mucinous Adneocarcinoma of the Appendix Cherif Boutros, Nader Hanna
441
Open cytoreductive Surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) has emerged as the procedure of choice for mucinous adenocarcinoma of the appendix (MAA), however is associated with substantial morbidity. We present a case of a totally laparoscopic R0- CRS-HIPEC for MAA. CRS included: right hemicolectomy, omentectomy, cholecystectomy, bilateral salpingo-oopherectomy, excision of the round and falciform ligaments and stripping of the peritoneum of the right diaphragm; followed by HIPEC through single inflow and outflow catheters. OR time was 380 mns and EBL was 100 mL. There was no postoperative morbidity. The patient was discharged home on postoperative day 8.
Laparoscopic Central Pancreatectomy and Pancreaticogastrostomy for the Management of a Proximally Migrated Pancreatic Stent Marc G. Mesleh, Frank Lukens, Michael B. Wallace, Horacio J. Asbun, John Stauffer A 43 year old female had a pancreatic stent placed during ERCP for elevated LFTs. The stent migrated proximally into the pancreas and was unable to be retrieved with multiple endoscopic attempts. After several episodes of pancreatitis, she was evaluated for surgical retrieval. A laparoscopic central pancreatectomy was performed to remove the stent, and a pancreaticogastrostomy was created for reconstruction.
SSAT Abstracts
S-1048