Laparoscopy: Historic, Present and Emerging Trends

Laparoscopy: Historic, Present and Emerging Trends Dr. George S Ferzli MD FACS Professor of Surgery - State University of New York (Downstate) Chairman of Surgery - Lutheran Medical Center, New York, USA

History of Laparoscopy A three bladed speculum was found in the ruins of Pompeii*. *A roman town buried by a volcano eruption near modern Naples, Italy - 79 AD). The first description dates to Hippocrates in Greece, for use of a speculum to visualize the rectum (460–375 BC).

History of Laparoscopy 1806: Philip Bozzini developed an instrument called a Lichtleiter (light-guiding instrument) 1853: Antoine Jean Desormeaux used Bozzini ’ s Lichtleiter 1867: Desormeaux used an open tube to examine the genitourinary tract

History of Laparoscopy Maximilian Nitze (1848 – 1906) invented the first cystoscope ( Nitze-Leiter cystoscope) using an electrically heated platinum wire for illumination . In 1887, he modified Edison`s light bulb and created the first electrical light bulb for use during urological procedures. Original carbon-filament bulb- Thomas Edison

History of Laparoscopy 1901: George Kelling, Dresden, Saxony (Germany) performed the 1st experimental laparoscopy, calling it ‘Celioscopy’. Kelling insufflated the abdomen of a dog with filtered air and used a Nitze cystoscope to look inside.

Hans Christian Jacobaeus (1879 – 1937) 1910: Swedish internist; first thoracoscopic diagnosis with a cystoscope in a human subject. Treatment of a patient with tubercular intra-thoracic adhesions. The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Münchner Medizinischen Wochenschrift, 1911

Bertram Bernheim 1911 : First laparoscopy at Johns Hopkins 12mm proctoscope into epigastric incision on one of Halstead’s patients to stage pancreatic cancer Bernheim called his procedure ‘organoscopy’ Findings confirmed on laparotomy

History of Laparoscopy 1920: Zollikofer discovered the benefit of CO 2 gas for insufflation 1938: Janos Veress developed a spring loaded needle for the induction of pneumoperitoneum. After World War II, the development of fiberoptics represented an important step forward for endoscopy 1966: Hopkins rod lens scope & cold light 1974: Dr Harrith M Hasson, MD working in Chicago, proposed a blunt mini-laparotomy which permitted direct visualization of the trocar entrance into the peritoneal cavity. It is popularly known today as Hasson‘s technique.

Kurt Semm (1927-2003) Once, while making a slide presentation on ovarian cysts; suddenly the projector was unplugged - with the explanation that “such unethical surgery should not be presented” In 1970, after becoming the chairman of Ob/Gyn at the University of Kiel, his co-workers demanded that he undergo a brain scan because, they said, “only a person with brain damage would perform laparoscopic surgery” German Engineer and Gynecologist. Introduced automatic insufflator, thermocoagulation ,loop knots, irrigation device in 1983, performed endoscopic appendectomy as part of A gynecologic procedure.

History of Laparoscopy 1985: Dr. Muhe (Prof Dr Med - Böblingen, Germany) performed the first successful laparoscopic cholecystectomy in a human. However, this was not well publicized until years later. The German Surgical Society rejected Mühe in 1986 after he reported that he had performed the first laparoscopic cholecystectomy.

Laparoscopy Takes Off 1988: 1st Lap cholecystectomy in the USA, Surgiport 1st available 1989: US TV picks up on “Key Hole” surgery EndoClip™ released 1990: Cuschieri (Aberdeen) warns on the explosion of endoscopy 1991: ‘Lap Chole’ is accepted and routine procedure 1992: The National Institutes of Health Consensus Conference concludes that laparoscopic cholecystectomy is now the preferred alternative to open cholecystectomy

VERESS NEEDLE 1938 - Janos Veress , of Hungary, developed the spring-loaded needle. to perform therapeutic pneumothorax (TB). Made of surgical stainless steel with a single trap valve. 2mm diameter x 80mm length It consists of an outer cannula with a beveled needle point for cutting through tissues.

GAS INSUFFLATION Controlled pressure insufflation of the peritoneal cavity is used to achieve the necessary work space for laparoscopic surgery. Automatic insufflators allow the surgeon to preset the insufflating pressure, and the device supplies gas until the required intra-abdominal pressure is reached.

Trocar The trocar has a blade with a shaft and body. The body includes a pointed tip which makes the initial incision in the abdominal wall of the patient. (Trocar diameters range from 2mm-30 mm)

Trocars Types: Cutting Pyramidal tipped Flat blade Noncutting Pointed conical Blunt conical Optical

Telescope There are three important structural differences in telescope available 1. 6 to 18 rod lens system telescopes are available 2. 0 to 120 degree telescopes are available 3. 1.5 mm to 15 mm of telescopes are available

Optic cables These cables are made up of a bundle of optical fibers glass thread swaged at both ends. The fiber size used is usually between 10 to 25 mm in diameter. They have a very high quality of optical transmission, but are fragile.

Dissecting & Grasping Forceps Atraumatic KELLY atraumatic Atraumatic, with hollow jaws MANGESHIKAR Grasping Forceps, serrated

General instruments Reusable three-piece design Available in 2 mm, 3 mm, 3.5mm, 5 mm and 10 mm sizes, with lengths of 20 cm, 30 cm, 36 cm and 43 cm. Choice of handle styles. Fully rotating 360° sheath. No hidden spaces that can trap operative blood and tissue debris.

Scissors HOOK SCISSORS, single action jaws METZENBAUM SCISSORS, curved, length of blades 12-17 mm, widely used as an instrument for mechanical dissection in laparoscopic surgery. STRAIGHT SCISSOR can give controlled depth of cutting because it has only one moving jaw.

TROCAR PLACEMENT BY QUADRANT Thoracic triangle Pelvic triangle 1 2 3 4

TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x

Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.

tro-car - [Fr., troisis , three + carre, side] noun a sharp-pointed surgical instrument fitted with a cannula and used especially to insert the cannula into a body cavity cannula - [L., dim of canna, reed] noun a tube that is inserted into a cavity by means of a trocar filling it’s lumen

Avoid competing for the same space: Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect)

No obstacle between trocar entry and target To avoid iatrogenic injuries.

Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Anatomic distribution of nerves across anterior abdominal wall Iliohypogastric nerve Ilioinguinal nerve

(adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Iliohypogastric n. Ilioinguinal n. Incision line/trocar sites vs. nerve distribution Epigastric a. Trocar site Pfannenstiel incision

Be aware of bladder location for suprapubic trocar

Trocar distance from the target organ depends upon the size of the patient. Individual trocars can be moved closer to the target along an axis line. Additional trocars can be added along the semicircular line.

Gold Standard Laparoscopic Procedures Today Laparoscopic cholecystectomy Laparoscopic RYGB for obesity Laparoscopic adrenalectomy Laparoscopic splenectomy

* 600,000 cholecystectomies annually in the U.S., 8%-20% have CBD stones, no consensus on optimal management. ** “No single clinical indicator is completely accurate in predicting CBD stones prior to cholecystectomy.” * Liu, TH et al. Ann Surg 234(1), July, 2001. **Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996

Liu TH et al: Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy. Ann Surg 234: 33-40, 2001

Laparoscopic US as a good alternative to intraoperative cholangiography (IOC) during laparoscopic cholecystectomy: results of prospective study. 685 IOC (35 cannot canulate cystic duct) 269 LUS (2 steatosis) IOC detected 4.5% common bile duct stones; LUS 6% IOC sensitivity 96.9%, specificity 99.2% LUS sensitivity 100%, specificity 99.6% Results: In this prospective study, LUS has been certainly as effective as IOC as a primary imaging technique for bile duct. It permitted to detect CBDS with a high specificity and sensitivity , and was not followed by an increase in CBDI. Hublet A et al Laparoscopic US as a good alternative to intraoperative cholangiography during lap chole: results of prospective study Acta Chir Belg . 2009 May-Jun Belgique.

Indocyanine Green (ICG) Injection: Shows the confluence between right and left hepatic ducts during hepatectomy. Enables identification of the cystic duct and CBD before dissection of Calot’s triangle during Cholecystectomy. Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009; 208(1):e1-e4

Indocyanine Green Injection (ICG) Advantages No need for dissection of Calot’s triangle No need for insertion of trans-cystic tube No exposure to radiation No space-occupying C-arm machine required Simple and convenient procedure Allergic reactions Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;208(1): e1-e4

Combined Laparoscopy and ERCP: Single Step – Treatment 45 pts underwent lap chole with intra-op cholangiogram 33 pts had succesful intra-op ERCP with extraction of common bile duct stones No post-op complications related to procedure (i.e. pancreatitis, bleeding, perforation) Mean hospital stay: 2.55+0.89 days No pts with signs or symptoms of retained CBD stones during mean post-op follow-up of 9+4.07 months Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7(4):338-46

Current Trends National Hospital Discharge Survey database 1979 to 2001: Frequency of ERCP vs CBDE Beginning of study: 47,000 CBDE’s per year End of study: 7,000 CBDE vs 43,000 ERCP Complication rates from CBDE 3.4% at beginning of study 17.4% at end of study “ ERCP has replaced the need for most but not all CBDE” “ Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CBDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CBDE experience” Livingston EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433

Public Health Problem #1: Laparoscopy in Bariatric Surgery OBESITY

Derived from Center for Disease Control and Prevention website www.cdc.gov Percent of Obese (BMI ≥ 30) in US Adults

County-level Estimates of Obesity among Adults aged ≥ 20 years: United States

Trocars - placed high, close to the costal margin. Trocar A - liver retraction. Trocar D - can be enlarged to allow for placement of a port. Trocar C - placed left of the midline for correct view of Angle of His. LAP-BAND C D E B A

Laparoscopic RYGB Multicenter, prospective, risk-adjusted data show that laparoscopic gastric bypass is safer than open gastric bypass, with respect to 30-day complication rate. LRYGB has become the standard of care Hutter et al. Ann Surg. May 2006 Massachusetts General Hospital, Boston .

National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health Statistics, 1979-1996. Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140: 1198-202. Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8. Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12. Popularity of Surgical Management Period or Decades Incidence of Surgery Reason for Change Late 1970’s Early 1980’s 25,000 procedures per year Innovative procedures gastroplasty loop GBP jejuno-ileal bypass Late 1980’s 1990’s 5,000 procedures per year Multifactorial: High M&M Ineffective long-term Perceived failure Surgeon experience 2000’s 80,000 to 110,000 procedures per year Multifactorial: Laparoscopy Long-term data Centers of Excellence

The first case of laparoscopic adrenalectomy was reported by Gagner in 1992. Laparoscopic Adrenalectomy

Less blood loss Less operative time!! Less hospital stay Less post operative pain Tiberio et al. Prospective RCT Surg Endosc. Jun 2008 Laparoscopic adrenalectomy

ACTH: adrenocorticotrophic hormone Indications for Adrenalectomy Unilateral adrenalectomy Bilateral adrenalectomy Hyperfunctioning tumors Aldosteronoma Cortisol-producing adenoma Virilizing tumors Pheochromocytoma Failed treatment of ACTH-dependent Cushing’s syndrome Nonfunctioning cortical adenoma a Cushing’s syndrome from primary adrenal hyperplasia Malignant tumors Adrenocortical carcinoma Malignant pheochromocytoma Adrenal metastasis (solitary without other metastatic disease) Bilateral pheochromocytoma symptomatic or enlarging adrenal myelolipomas, ganglioneuroma

a Relative contraindications Contraindications for Laparoscopic Adrenalectomy Local tumor invasiveness Regional lymph node involvement Large tumor size larger than 10 to 12 cm a Prior nephrectomy, splenectomy, or liver resection on the side of the adrenal lesion a

Laparoscopic Splenectomy-Indications Idiopathic thrombocytopenic purpura ITP/HIV + Thrombotic thrombocytopenic purpura Hereditary spherocytosis Auto-immune hemolytic anemia Splenic cysts Evan’s syndrome Felty’s syndrome Hypersplenism (portal hypertension) Non Hodgkin’s lymphoma Hodgkin’s lymphoma Lymphocytic leukemia Myelocytic leukemia Tricholeukocytic leukemia Myelocytic splenomegaly Splenic tumor

Laparoscopic splenectomy Significantly less pulmonary, wound, and infectious complications. Longer operative times Winslow (meta-analysis). Surgery. 2003 Oct;134(4):647-53

Laparoscopic Procedures with equivalence Laparoscopic hernia repair Laparoscopic appendectomy Laparoscopic fundoplication

Laparoscopic Inguinal Hernia Repair

The Ebers Papyrus 1550 BC, Entitled “Beginning of the Secret of the Physician” Heat application was one of the methods to reduce a strangulated hernia. The mummy of Meren-Ptah (19th dynasty) shows a sign of an open wound resulting from surgical interference. If thou examinst a swelling of the covering of his belly’s horns above his pudenda (sex organs) then thou shalt place thy finger on it and examine his belly and knock on the fingers (percuss) if thou examinst his that has come out and has arisen by his cough. Then thou shalt say concerning it: it is a swelling of the covering of his belly. It is a disease which I will treat”.

Hernia - Historic Perspective Galen of Pergamum (AC 129-179) who was a surgeon to the gladiators practiced ligation of the sac and cord with amputation of the testicle. Guy de Chauliac (AC 1300-1368) in his book Chirurgia Magna: laxatives, hang patient from his legs, bed rest for 50 days.

Trocar placement: Transabdominal Preperitoneal (TAPP) Totally Extraperitoneal (TEP) Additional trocar

What are indications for laparoscopic inguinal hernia repair? Recurrent hernia Avoids scar tissue Visualizes occult hernia Bilateral hernia Decreased pain Earlier return to work No difference in recurrence or complication Obese / Athletic patients Definitive diagnosis Reduced infection in susceptible population Gilmore’s groin Patients with contralateral injury to vas deferens Less chance to injure other vas

Are there contraindications to lap. inguinal hernia repair? Contraindications Patients for whom general anesthesia and pneumoperitoneum are risks (cardiac, pulmonary disease) Relative Contraindications Prior pre-peritoneal surgery (prostate, hernia, vascular, kidney transplant) Prior laparotomy Ascites Strangulated hernia Giant scrotal hernia Anticipated bleeding (patients on anti-coagulation)

Management of recurrent inguinal hernias Kamal MF Itani MD 1 , Robert Fitzgibbon Jr MD 2 , Samir S Awad MD 3 , Quan-Yang Duh MD 4 , George S. Ferzli MD5 1 Boston VA Health Care System and Boston University, Boston MA 2 Creighton University, Omaha NE 3 Michael E DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX 4 San Francisco VA Medical Center and University of California San Francisco, San Francisco CA 5 SUNY Downstate Medical Center and Lutheran Medical Center, Brooklyn NY

Role of the Patient in Recurrence HEAD Score : Hernia of the Adult Disease Score Attempt to individualize treatment based on 8 factors. Courtesy of Dr. Christian Peiper

2. Do we have an answer for groin pain after hernia repair?

Nerves prone to injury anterior and posterior

Groin Pain Incidence * Groin pain or discomfort lasting more than 3 months after groin hernia repair. Intern. Assn. for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain . 1986; 3 (suppl): 1–226. Author # of Pts Pain * Pain Severe Outcome of Pain A. S. Poobalan 2001 226 30% > 3 mo Morten Bay-Nielsen 2001 1166 28.7% > year 3% S. Kumar 2002 454 30% >21 mo C. A. Courtney 2002 4062 > 3 mo 3% > 2.5 yrs 71% have pain Severe in 22% Mild in 45% Marcello Picchio 2004 593 25% > 1 yr 6%>1 yr A. M. Grant 2004 928 9.7%>1 yr 1.8% > 5 yrs Jrg Kninger 2004 208 36% (Shouldice) 31% (Lichtenstein) 15% (TAPP) > 52 mo Ulf Fränneby 2006 2456 31% >24 to 36 mo Sergio Alfieri 2006 973 9.7% > 6 mo 2.1 %> 6 mo Mild 4.1% > 1yr Severe 0.5% > 1yr E. K. Aasvang 2006 210 34.3% >1year Less pain 75.8% Same pain 16.7% More severe 7.5% > 6.5 years

Quality of Life Author Pts Pain affects the quality of life Morten Bay-Nielsen 2001 1166 16.6% S Kumar 2002 454 18.1% Jrg Kninger 2004 208 14% (Shouldice) 13% (Lichtenstein) 2.4% (TAPP) Ulf Fränneby 2006 2456 6% EK Aasvang 2006 210 Nb 24.8% 6% after 6.5 years Sergio Alfieri 2006 973 11.3% to 14.2%

Causes and Risk Factors of Groin Pain Anatomical Variation Innervation symmetry - 40.6% Normal distribution - 20.3% “ Normal” anatomic pattern - 56.3% Mesh repair No clear correlation between use of mesh and chronic pain Age Studies disagree on correlation between older age and post-herniorrhaphy pain Pre-operative pain Pain associated with hernia before repair is associated with post-operative pain BMI No correlation found between elevated BMI and post-operative pain Post-operative complications Postoperative complications linked to an increased risk for long term pain Recurrent hernia Day case surgery Open versus laparoscopic Recurrence associated with recurrent pain The probability of developing chronic pain is 2.5 times higher in day-case patients, controlling for age Open repair strongly correlated with post-operative pain compared to laparoscopic repair

What are recommendations for prevention of chronic pain? Conclusions Level 1B Material reduced meshes have some advantages with respect to longterm discomfort and foreign body sensation in open hernia repair (when only considering chronic pain). Level 2A Prophylactic resection of the ilioinguinal nerve does not reduce the risk of chronic pain after hernia surgery. Level 2B Identification of all inguinal nerves during open hernia surgery may reduce the risk of nerve damage and postoperative chronic groin pain. Treatment of chronic pain Level 3 A multidisciplinary approach at a pain clinic is an option for the treatment of chronic post herniorrhaphy pain. Surgical treatment of specific causes of chronic post herniorrhapy pain can be beneficial, such as resection of entrapped nerves, mesh removal in mesh-related pain, removal of endoscopic staples or fixating sutures. European Hernia Society Guidelines: Treatment of Inguinal Hernia in Adult Patients

Laparoscopic Ventral Hernia:Is the Abdomen a Weakness in the Human Race ?

Incidence of Ventral Hernias Around 10% of all laparotomies will generate incisional hernias. The bigger the incision, the higher the risk. ~77% are median hernias ~17% are lateral hernias ~6% are iliac hernias Direct closure have a high recurrences incidence (50%). The rate increases (58%) with repair of recurrent hernias. Significant reduction in recurrences is achieved when meshes are used. Luijendijk RW, et al. A Comparison of Suture Repair with Mesh Repair for Incisional Hernia .NEJM 2000; 343:392-398

Factors Influencing Ventral Hernia Occurrence The most important functions of the abdominal wall are protection, compression and retention of the abdominal contents, flexion and rotation of the trunk and forced expiration. Endogen Exogene Others Age > 45 Sutures Emergency BMI > 25 Length of incision Intra-abdominal Previous operation Contamination pressure Anemia Medication Shock Type of incision Smoker Corticoïds Aneurysm/Marfan (+30% risks)

Hypothesis: In midline incisions closed with a single layer running suture, the rate of wound complications is lower when a suture length to wound length ratio of at least 4 is accomplished with a short stitch length rather than with a long one. Surgical site infection occurred in 35 of 343 patients (10.2%) in the long stitch group and in 17 of 326 (5.2%) in the short stitch group (P=0.2). I ncisional hernia was present in 49 of 272 patients (18.0%) in the long stitch group and in 14 of 250 (5.6%) in the short stitch group (P<.001). Conclusion: In midline incisions closed with a running suture and having a suture length to wound length ratio of at least 4, current recommendations of placing stitches at least 10mm from the wound edge should be changed to avoid patient suffering and costly wound complications. Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study Daniel Millbourn, MD; Yucel Cengiz, MD, PhD; Leif A. Israelsson, MD, PhD Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com

Significant predictors of surgical site infection and incisional hernia a Effect of Stitch Length on Wound Complications After Closure of Midline Incisions; A Randomized Controlled Study, Millbourn, D MD; Cengiz, Y MD, PhD; Israelsson, L MD, PhD Arch Surg/vol 144 (No. 11), Nov 2009 www.archsurg.com Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CI, confidence interval; OR odds ratio; SL, suture length; WL wound length A Results of logistic regression analysis. All recorded variables were included in the model and removed by a backward reduction strategy if nonsignificant. Predictor Regression Coefficient (SE) OR (95%CI) Surgical site infection Wound contamination 1.03 (0.48) 2.81 (1.09-7.25) Being diabetic 1.01 (0.38) 2.73 (1.30-5.72) Long stitch length 0.77 (0.31) 2.15 (1.17-3.96) Incisional hernia Male sex 0.76 (0.34) 2.14 (1.10-4.15) Higher BMI 0.05 (0.02) 1.05 (1.01-1.10) Longer operation time 0.005 (0.002) 1.01 (1.002-1.01) Surgical site infection 1.16 (0.40) 3.18 (1.44-7.02) SL to WL ratio <4 1.32 (0.52) 3.73 (1.36-10.26) Long stitch length 1.44 (0.34) 4.24 (2.19-8.23)

Prospective Clinical Trial of Factors Predicting the Early Development of Incisional Hernia after Midline Laparotomy 6 months analysis after operation of numerous demographic, clinical, treatment and outcomes-related peri-operative factors to determine statistical association with development of incisional hernia. Four covariates independently predictive of incisional hernia were studied: Body mass index (BMI) > 24.4kg/m2 ; fascial suture to incision ratio (SIR) < 4.2 ; deep surgical site, deep space, or organ infection (SSI ); and time to suture removal or complete epithelialization >16 days (TIME). Conclusion: The hernia risk scoring system equation [p(%) = 32(SIR) + 30(SSI) + 9(TIME) + 2(BMI)] provided accurate estimates of incisional hernia according to stratified risk groups based on total score: low (0 to 5 points), 1.0%; moderate (6 to 15 points), 9.7%; increased (16 to 50 points), 30.2%; and markedly increased (>50 points), 73.1% JACS, Volume 210, Issue 2, pp 210-219. Radovan Veljkovic, MD, PhDa, Mladjan Protic, MDa, Aleksandar Gluhovic, MDa, Zoran Potic, MSb, Zoran Milosevic, MD, PhDa, Alexander Stojadinovic, MD, FACScd

Laparoscopic Repair of Incisional Hernias  wound complications  recurrence rate  LOS  pain coverage of “Swiss cheese” abdomen

Secure periphery of mesh with tacker Approximately 1cm apart

Potential Mesh-Related Complications: Infection Intestinal adhesions Bowel obstructions Erosion of the prosthesis into the adjacent hollow viscous Contraction of prosthesis

Processing of Biomaterials Cadaveric, Bovine, Porcine, Equine: removal of all live cells and removal of all nuclear tissue to prevent rejection by the host . Cross-linking: serve to form either an intermolecular or an intramolecular cross-link between two aminoacids along protein structure (HDMI and EDC are in common use) . Crosslinked products are more resistant to collagenase degradation (more stable in infected fields where collagenases are secreted by bacteria). Rapid dissolution in the presence of enteric contents (fistulas) . Must be placed in direct contact with healthy tissue, under no tension and should not be usedto bridge the defect.

Comparison of Biologic Grafts – Overview of Gaertner Study Alloderm Bulge Alloderm Translucency Gaertner, W et al. Experimental Evaluation of Four Biologic Prostheses for Ventral Hernia Repair. J Gastrointest Surg July 2007 Thickness at the defect area diminished significantly at 6 months with both Veritas and AlloDerm (P<0.05), so much so that they became translucent. Permacol and Peri-Guard, the mean defect area and thickness were virtually identical to when they were originally installed 6months earlier. Tensile strength of the material itself after 6 months was significantly reduced for the non-cross-linked prostheses (Veritas and AlloDerm) compared to the cross-linked prostheses (Peri-Guard and Permacol). Stretching, bulging, and translucency were routine with AlloDerm.

Level of Complexity Grade 1 Low risk of infection Low risk of complications Grade 2 Smoker Immunosuppressed Obese Diabetic Grade 4 Active infection Infected mesh Grade 3 Contamination risk Stoma present Violation of bowel wall Previous Wound infection Grade 5 Traumatic fascia loss Extensive fascia loss Percent Performed Open Patients with co-morbid conditions have up to 4x increase in wound-infection rates Open incisional hernias are 10x more likely to have infection than a clean surgical case Infected mesh commonly results in a 2 nd procedure for removal Synthetic Biologic

Material Functions for Soft Tissue Repair Synthetics Autografts Good mechanical properties Low cost High foreign body reaction Infection up to 8% 1 Can cause pain Native Tissue Good Mechanical Properties Donor Site Morbidity Many patients unqualified Strong reinforcement Biocompatible Supports ingrowth Ease of handling Ability to vascularize Xeno/Allo graft

Components Separation Developed by Dr. Ramirez in the late 80’s Employs the use of autologous myofascial tissue to effect abdominal wall closure Bilateral relaxation incisions 2cm lateral to the external oblique from costal margin to level of symphasis pubis Blunt separation of external oblique layer from underlying internal oblique layer taking care not to interrupt vascular/nerve supply May employ undermining of one or both posterior rectus sheaths to achieve further medial advancement **Provides dynamic support of the abdominal girdle**

Grevious MA. Cohen M. Shah SR. Rodriguez P. Structural and functional anatomy of the abdominal wall. Clinics in Plastic Surgery. 33(2):169-79, v, 2006 Apr. External oblique Internal oblique Transversus abdominis Rectus abdominis Components Separation

Laparoscopic Appendectomy Endo-loop

APPENDECTOMY Alternatively, an appendectomy can be performed through a trocar in the umbilicus and two trocars in the suprapubic area medial to the epigastric vessels for a superb cosmetic result (if an extended right hemicolectomy is to be performed, the hepatic flexure positioning is preferred.)

Laparoscopic Appendectomy Evidence-based Medicine Clear advantage in children* - Less wound infection, LOS, ileus - More OR time, intra-abdominal abscess Controversies in adults - Cost, obese patients, severe appendicitis *Aziz et al. Ann Surg 2006 - Prelude to NOTES

LAPAROSCOPIC PROCEDURES WITH CLEAR ADVANTAGES.

Laparoscopic Heller’s Cardiomyotomy Technically feasible Short recovery time Less overall complication rates

Anti-reflux surgery 1945 to present Multiple methods and techniques: Nissen fundoplication Dor wrap Hill gastropexy …. Different approaches: Laparotomy vs laparoscopy Thoracotomy vs thoracoscopy Rudolph Nissen, MD INFLUENTIAL PEOPLE: Lortat-Jacob, MD AndreToupet, MD Jacques Dor, MD Ernst Heller, MD Rudolph Nissen MD Ivor Lewis, MD J. Leigh Collis, MD K. Alvin Merendino, MD Lucius Hill, MD Ronald Belsey, MD Alan Thal, MD

Nissen’s Fundoplication Technique

Esophageal Hiatus Liver Esophagus Left crus Right crus Aorta

Hiatal Defect Chest cavity Stomach Left crus

Polypropylene mesh Esophagus Do not use metal tacks Biologic mesh? dual mesh? No mesh at all? (remember original Toupet repair) Mesh Wrap Circular mesh Fundoplication

Laparoscopic Surgery in Colorectal Diseases

NOTE: If proximal divided end of colon can reach through the skin there has been sufficient dissection of splenic flexure providing a tension-free anastomosis.

HEPATIC FLEXURE COLON RESECTION The ileum is more mobile than the transverse colon, which can still be delivered adequately at this level. A B Tension-free anastomosis Trocar C is used for GIA division of distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis). C

LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)

Laparoscopic colorectal surgery Cochrane Systematic review of short term outcomes in 25 RCTs showed that laparoscopic colorectal surgery had: Longer operative time Less intraoperative blood loss Less postoperative pain less postoperative ileus Better postoperative pulmonary function Less total and local morbidity Less postoperative hospital stay Similar general morbidity and mortality Better quality of life (within 30 days) Schwenk et al. 2005 Jul 20;(3):Cochrane Database 003145 Cochrane Systematic review of long term outcomes showed: Similar port-site metastases and wound recurrences Similar cancer-related mortality at maximum follow-up Similar tumor recurrence Similar overall mortality Kuhry et al. Cancer Treat Rev. Oct 2008

Consensus Review of Optimal Perioperative Care in Colorectal Surgery, Enhanced Recovery After Surgery (ERAS) Group Recommendations Fast-track Protocol No oral bowel preparation Pre operative fasting of 2 hours for liquids and 6 hours for solids. Carbohydrate loading Single dose antibiotic prophylaxis. No routine use of nasogastric tubes. Use of drains not advisable. Oral diet at will after surgery. Conventional Protocol Oral bowel preparation Pre operative fasting of 6 hours Prolonged antibiotic use. Nasogastric tubes used routinely. Drains routinely used. Delayed oral intake.

Less frequent Laparoscopic procedures Liver Surgery Pancreas Surgery

Laparoscopic hepatectomy First performed 1994 by Huscher et al A safe procedure in experienced hands Resection devices: Staplers Bipolar vessel sealing (Ligasure) Radiofrequency U/S dissector Nd-YAG laser Laparoscopic left hemihepatectomy (resection of segments 2, 3, and 4). (A) Intraoperative view showing ischemic delineation of the left liver. Note the vascular endoscopic stapler encircling the left Glissonian pedicle. (B) Schematic view. The stapler is closed, and ischemic delineation of the left liver is obtained. (C) Intraoperative view. The stapler is fired, and the left main Glissonian pedicle is transected (arrows). (D) Schematic view. The stapler is fired

Pulitan ò C and Aldrighetti L Nat Clin Pract Gastroenterol Hepatol (2008) Outcomes of laparoscopic hepatectomy

Laparoscopic pancreatectomy Pancreaticoduodenectomy Total splenopancreatectomy Spleen-preserving total pancreatectomy Distal splenopancreatectomy Spleen-preserving distal pancreatectomy Central pancreatectomy Enucleation Procedures are technically challenging Long learning curve High volume center improves clinical outcome

DISTAL PANCREATECTOMY D E C B A Trocars “A” and “B” divide gastrocolic ligament GIA is introduced through “D”

Laparoscopic pancreatectomy Vs. open Finan et al. Am Surg. Aug 2009 Laparoscopic and open distal pancreatectomy: a comparison of outcomes. There was no significant difference in the incidence of postoperative morbidity or mortality There was no significant difference in the rate of all pancreatic fistula formation or clinically significant leaks Lparoscopic technique had decreased: operative time blood loss length of stay in the lap group. Conclusion Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers.

Laparoscopic Urologic procedures Undescended testis Varicocelectomy Retroperitoneal fibrosis Lymph node dissection Bladder neck suspension Bladder diverticulum Patent urachus Nephrectomy Prostatectomy

RT. KIDNEY RESECTION Subxiphoid port (D) - liver retraction Trocar A - parallel to vena cava (perpendicular approach to rt. renal vessels and rt. adrenal vein – additional trocar E may be placed more laterally and posterior to trocar A if needed.) B C D A E

PROSTATECTOMY A B C Trocars – added as needed along semicircular line. i.e., during a prostatectomy, another trocar is added between A and B. Another trocar may be added between B and C allowing the surgeon and assistant surgeon on the opposite side to each use both hands.

Minimally invasive neck surgery

Minimally invasive neck surgery Endoscopic Central Lateral “ Other” (transaxillary, transpectoral, transoral) Minimally invasive MIVAT (min. invasive video assisted thyroidectomy) MIVAP (min. invasive video assisted parathyroidectomy) Robotic assisted Inferior parathyroid release in Minimally invasive thyroidectomy

Cosmetic results Open surgery scar Minimally invasive / endoscopic scars

Conclusions MIVAT and MIVAP yield equivalent endocrine results as open procedure Oncologic result is equivalent in selected patients Equivalent safety profile as open procedures Postop pain is decreased Patient satisfaction with procedure and cosmetic result is significantly increased (Miccoli et al., RCT, Surgery. 2001) Yet: What about large masses?! It is not a ‘niche surgery’!

Emerging Technologies Robotics SILS NOTES Trocarless laparoscopy ENDOBARRIER

History of Robotics Leonardo da Vinci developed one of the first robots in 1495 – an armored knight for the purposes of entertaining royalty.

What Robotics Aimed to Improve in Laparoscopy Surgeon operates from a 2D image Straight, rigid instruments (limited range of motion) Instrument tips controlled at a distance Reduced dexterity, precision & control Unsteady camera controlled by assistant Dependent on assistant for surgical support through accessory port Greater surgeon fatigue Makes complex operations more difficult

Surgical Robots AESOP (Automated Endoscopic System for Optimal Positioning) - Voice activated mechanical arm - Steadier than human, never tires da Vinci ® - FDA approval in 2002 - Laparoscopic instrumentation controlled by the surgeon, positioned remotely at a console

Development of da Vinci ® Defense Advanced Research Projects Agency (DARPA) for military research of remote battlefield surgery Cholecystectomy performed remotely via telesurgery from 300 miles away Intuitive surgical created in 1999 after acquiring patent rights from military First robotic prostatectomy performed in 2001

da Vinci ® Surgical System U.S. Installed Base 1999 – 2006

What is the da Vinci ® Surgical System? State-of-the-art robotic technology Surgeon in control Assistant has direct access

Surgeon directs precise movements of instruments in the slave unit using console controls. What is the da Vinci ® Surgical System?

Robotic Scrub Nurse “Penelope”

Laparoscopic instruments are rigid with no wrists EndoWrist ® Instrument tips move like a human wrist Allows surgeon to operate with increased dexterity & precision. No tremor Wrist and Finger Movement

Disadvantages of da Vinci ® Robot Expensive - $1.4 million cost for machine - $120,000 annual maintenance contract - Disposable instruments $2000/case - Hospital reimbursement same DRG Steep surgical learning curve Loss of tactile feedback Increased staff training/competence Increased OR set-up/turnover time!!

SILS Single Incision Laparoscopic Surgery

SILS – Single Incision Laparoscopic Surgery SSA – Single Site Access SPA – Single Port Access SAS – Single Access Site SPL – Single Port Laparoscopy LESS – Laparo Endoscopic Single Site Surgery TUES – Trans Umbilical Endoscopic Surgery What does that stand for ?

SILS Urology Renal transplant Cholecystectomy Gastric band surgery Colectomy

SILS Ergonomically difficult ?! Training !

N.O.T.E.S. Natural Orifice Transluminal Endoscopic Surgery

A Recent History of “New Minimal Access” Surgery 2000 Flexible endoscopic endoluminal therapy for GERD 2003 Kalloo et al transgastric peritoneoscopy with flexible endoscope 2004 Rao and Reddy reported on transgastric cholecystectomy and appendectomy in patients 2006 summit meeting: NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research) formed

Alleged NOTES Benefits No surface incision Reduced surgical site infection Reduced visible scarring Reduction in pain analgesics Quicker recovery time Reduction in hernias, adhesions Advantages in the morbidly obese

Notes- Transvaginal Video-endoscope entering through the posterior vaginal fornix

NOTES - Transgastric Courtesy of N Reddy, Hyperbad India 2005

Trocarless Laparoscopy The development of magnetically controlled and anchored, intracorporeal surgical instruments and camera introduced through a single trocar.

A. Schematic representation of conventional transabdominal trocar and instrument (left) and proposed magnetically anchored and guided instrument/camera (right). B. Schematic representation of typical multitrocar laparoscopic surgery (left) and proposed single trocar surgery through which multiple MAGS instruments are introduced and deployed.

The novel use of ‘Light’ trocar

A. Schematic representation of prototype internal camera fully deployed. B. Internal view of camera fully deployed.

A. Schematic representation of prototype paddle-type retractor fully deployed. B. Internal view of prototype elevating porcine spleen.

Endobarrier The EndoBarrier gastrointestinal liner works by creating a physical barrier between ingested food and the intestinal wall. Food bypasses the duodenum and proximal jejunum as it does in a Roux-en-Y gastric bypass.

Endo-Barrier Benefits include: Weight loss ADA: glycemic control in Type 2 diabetes Safe alternative to gastric bypass Non-invasive procedure Rapid recovery Lower costs

Feb 2010: Schouten Objective: To determine the safety and efficacy of EndoBarrier Gastrointestinal Liner Duodenal-jejunal bypass sleeve Designed to achieve weight loss in morbidly obese patients. First European experience 41 patients included 30 underwent sleeve implantation. 11 - diet control group. All followed the same low-calorie diet during the study period.

2010: Schouten et al. Role of EndoBarrier 26 devices were successfully implanted Mean procedure time -35 min (range: 12–102 min) No procedure related adverse events. Mean excess weight loss after 3 months 19.0% device vs 6.9% for control ( P < 0.002) Type 2 diabetes mellitus 8 pts with baseline Type 2 diabetes mellitus Improvement in 7 patients during the study period Schouten et al. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg. 2010 Feb;251(2):236-43.

2010: Schouten et al. Role of EndoBarrier The EndoBarrier Gastrointestinal Liner Feasible and safe noninvasive device Excellent short-term weight loss results. Type 2 DM Significant positive effect Long-term randomized and sham studies necessary Schouten et al. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg. 2010 Feb;251(2):236-43.

Diabetes Considered major public health problem – emerging as a world wide pandemic. In 1995 ~ 135 million people worldwide Currently 240 million, expected to rise to close to 380 million by 2025 Complications Peripheral vascular disease (PVD) accounts for 20-30% 10% of cerebral vascular accident Cardiovascular disease accounts for 50% of total mortality 1. Venkat et al Diabetes–a common, growing, serious, costly, and potentially preventable public health problem. Diabetes Res Clin Pract. 2000; 5 (Suppl2): S77–S784. 2. H. King et Global burden of diabetes, 1995-2025: prevalence, numerical estimates and projections. Diabetes Care 21 (1998) 1414-1431. 3. Annals of Surgery. Volume 251, Number 3, March 2010

Prevalence of Diabetes From 1980 through 2006, the number of Americans with diabetes tripled (from 5.6 million to 16.8 million). ~24 million in 2009.

CDC. National Diabetes Fact Sheet, 2007. Source: 2003 –2006 National Health and Nutrition Examination Survey estimates of total prevalence (both diagnosed and undiagnosed) were projected to year 2007.

Metabolic Syndrome Also Known as: 1. Syndrome “X” 2. Insulin Resistance Syndrome 3. Reaven’s Syndrome 4. Deadly Quartet 5. CHAOS C oronary Artery Disease H ypertension A dult Onset Diabetes O besity S troke

Morbidity Obesity Associated Conditions Diabetes Hypertension Sleep apnea Congestive heart failure Hyperlipidemia Stroke Coronary artery disease Osteoarthritis Gastroesophageal reflux disease Non-alcoholic fatty liver Psychological disturbances

Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-37. Sjostrom L, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351: 2683-93. Long-term Weight Control Analysis Studies Type and Size Effect on Weight Effect on Comorbidities Buchwald et al. Meta-analysis n = 22,094 pts Mean excess weight loss: 61% Resolution of: Diabetes: 70% HTN: 62% Sleep apnea: 86% Swedish Obese Subject trial (SOS) Prospective matched cohort n = 4,047 pts At 10 years: Med: 1.6% gain Surg: 16% loss Improved by surgery: Diabetes Lipid profile HTN Hyperuricemia

Schauer et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003 Oct; 238 (4): 467-84 1160 patients underwent LRYGBP 5-year period LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM Fasting plasma glucose and HBA1C normalized (83%) or markedly improved (17%) in all patients Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic

Rates of Remission of Diabetes Adjustable Gastric Banding Roux-en-Y Gastric Bypass Biliopancreatic Diversion >95% (Immediate) 48% (Slow) 84% (Immediate)

“ Gastric bypass and biliopancreatic diversion seem to achieve control of diabetes as a primary and independent effect, not secondary to the treatment of overweight.” Potential of Surgery for Curing Type 2 Diabetes Mellitus. Rubino, Francesco, MD; Gagner, Michel MD, FACS, FRCSC Annals of Surgery; 236 (5): 554-559, November 2002 2002: Antidiabetic Effect of Bariatric Surgery: Direct or Indirect?

Historical Perspective 1955- Friedman 3 patients with poorly control DM 3-4 days after subtotal gastrectomy all 3 pateints showed an improvement in their DM Occurred sooner than associated weight loss Patients later regained their weight without an associated loss of glucose control or glycosuria Mingrone 1977 : Case report Young, non obese woman with DM who underwent BPD for chylomicronemia Plasma insulin and blood glucose levels normalized within 3 months Bittner –1981- subtotal gastrectomy and gastrointestinal reconstructions that excluded duodenal passage (B2 and RYGB Lowered plasma glucose and insulin Conclusion: Plasma glucose and insulin fall rapidly post-operatively antidiabetic medications can be reduced or stopped shortly after gastrointestinal bypass interventions Rubino F. Bariatric Surgery:effects on glucose homeostasis. Curr. Opin. Clin. Nutr. Metab. Care 9: 497-507 Bittner R. Homeostasis of glucose and gastric resection: the influence of food passage through the duodenum Z Gastroenterology 1981; 19: 698-707. Friedman NM et al. The amelioration of diabetes mellitus following subtotal gastrectomy. Surg. Gynecol. Obstetr. 1955; 100:201-204

2004: Duodenal-Jejunal Exclusion - Foregut

Slides taken from: DIABETES IS NO LONGER A HOPELESS DISEASE The Guilty Gut Walter Pories, MD, FACS, Chief, Metabolic Institute East Carolina University Greenville, North Carolina 2006:

2004: “ Results of our study support the hypothesis that the bypass of duodenum and jejunum can directly control type 2 diabetes and not secondarily to weight loss or treatment of obesity.” Effect of Duodenal-Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes: A New Perspective for an Old Disease. Rubino, Francesco, MD; Marescaux, Jacques MD, FRCS Annals of Surgery; 239 (1): 1-11, January 2004

Double blind study: 16 patients assigned to LRYGBP and 16 Pts to LSG Patients reevaluated on the 1st, 3rd, 6th, and 12th mos Results: No change in ghrelin levels after LRYGBP Significant decrease in ghrelin after LSG ( P < 0.0001) Fasting PYY levels increased after either surgical procedure ( P <= 0.001) Appetite decreased in both groups but to a greater extend after LSG Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Karamanakos et al Ann Surg . 2008 Mar; 247(3): 401-7.

“ PYY levels increased similarly after either procedure. The markedly reduced ghrelin levels in addition to increased PYY levels after LSG, are associated with greater appetite suppression and excess weight loss compared with LRYGBP” March 2008: Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Karamanakos et al Ann Surg. 2008 Mar; 247(3): 401-7. March 2008:

2009: Ferzli et al. Results at 12 months A ll subjects consistently felt relief from fatigue, pain and/or numbness in the extremities, polyuria, and polydypsia. Clinical resolution was obtained for one patient, and the preoperative diabetic medication requirements decreased for most of the other patients. The subjects demonstrated an overall improved HbA1c (from 9.4% to 8.5%) and fasting blood glucose level (from 209 to 154 mg/dl).

The Diabetes Surgery Summit Consensus Conference Rubino et al. Annals of Surgery. Vol 251, Number3,300-405, March 2010 45% of type 2 patients with diabetes world-wide demonstrate a BMI less than 30 ADA : “ Bariatric Surgery should be considered for adults with BMI > 35Kg/m2 And type 2 diabetes ,especially if the diabetes is difficult to control with lifestyle And pharmacologic therapy

The Surgeon and the Diabetologists

And it ought to be remembered that there is nothing more difficult than to take the lead in the introduction of a new order of things, because the innovator has for enemies, all those who have done well under the old conditions. Nicolo Machiavelli (1469-1527), The Prince, 1513

Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007) Patient Duration of Type 2 Diabetes Pre-Operative Medication 1 Year Medication Requirement #1 19 Metformin 850mg One tablet daily Metformin 850 mg half tablet daily #2 10 30/10 Units Insulin 30/10 Units Insulin #3 12 40/20/20/20 Units Insulin 30 Units occasionally at night #4 12 2 Metformin 850mg daily; 40/20 Units Insulin 1 Metformin 850mg daily; 5 Units n occasionally #5 12 40/20 Units Insulin 5 Units Insulin three times per week #6 * 6 20/12 Units Insulin No Medication #7 4 Clormin 1000mg daily; 30/20 Units Insulin Diaformin 500mg daily; 30/20 Units Insulin

Clinical Evaluation of the Effect of Duodenal-Jejunal Bypass on Type 2 Diabetes (June 2007) The mean HBA1c at pre-op and 1 year was 9.371 and 8.500 respectively FBG at pre-op and 1 year were 208 and 154 respectively for the seven patients (p=0.057) Lipid profiles improved with lower total cholesterol levels and triglycerides 1 year Mean (SEM) Pre vs post op Correlation P value* HBA1C Pre-op 9.371 (0.85) -0.040 0.933 HBA1C 1yr 8.500 (0.67) FBG Pre-op 208.86 (22.50 0.74 0.057 FBG 1YR 154.86 (39.9) Cholesterol preop 183.71 (11.5) 0.632 0.128 Cholesterol 1yr 186.00 (19.9) TG pre-op 112.43 (27.7) -0.245 0.596 TG 1yr 127.29 (25.3) Cpep pre-op 1.343 (0.29) -0.245 0.205 Cpep 3 months 1.200 (0.32)

Laparoscopy: Historic, Present and Emerging Trends

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