1

NESA Days 2006AnInterdisciplinaryEndoscopicalConference

January19-21,2006

HiltonHotelBerlin

�

�

NESADays2006

AnInterdisciplinaryEndoscopicalConference

January19-21,2006 HiltonHotelBerlin

www.nesa-days.com

�

�

WelcomeoftheNESADays2006................................................................................. 7

Internationalscientificcommittee.............................................................................. 12

Scientificprogramme................................................................................................... 13

Invitedspeakers........................................................................................................... 25

Abstractsoftheinvitedspeakers................................................................................ 27

Usefulinformation........................................................................................................ 65

�

�

NESAwasfoundedinOctober2004asaninitiativeofsurgeonsfromdifferentdisciplineswhowantedtobuildan international interdisciplinarynetworkofexperts.Theideawastobringtogetherautho-ritative professionals, with their knowledge andtheir scientific and practical experience, in ordertosimplify,standardizeandoptimizesurgicalpro-ceduresforthebenefitofourpatients.

TheevaluationandthescientificprojectsofNESAfocusonfivedisciplines:generalsurgery,obstetricsandgynaecology,uro-logy,otolaryngologyandanaesthesiology.NESAnow–14monthsafteritscreation-includesmembers,departments,hospitalsandinternationalorganisations in27countries.WeareproudthatduringtheNESADays2006expertsofnotableinternationalreputationwillpresentawidevarie-tyofre-evaluatedandoptimizedsurgicalendoscopicprocedures,alongwith new developments in basic sciences. The NESA Days will providetheopportunity for surgeons fromdifferentdisciplinesandcountries toupdatetheirknowledgeintheirownprofessionandtobeexposedtonewideasandtechniquesinotherdisciplines.Followingthebasic ideaofNESA,Iexpectthattheinterdisciplinaryex-change and sharing of knowledge will stimulate new thinking and newideas–forthebenefitofthepatients.Youwillfindahighlyprofessionalplatformtodiscussnewideasandtobroadenyourknowledgeincurrentsurgicalproceduresaswellasnewdevelopments.Iencourageyoutobeactiveduringthecongress,challengingyourcolleaguesandthespeakers.AndIamsureyouwillfindaculturalprogramwhichgivesyouexcellentopportunitiestoenjoyyourfriendsandtoacquirenewones.IhopewewillseeyouallagainintheNESADays2007.

Dr. Francesco De Meo Director, The New European Surgical Academy

�

Dearcolleagues:

OnbehalfoftheNewEuropeanSurgicalAcademy(NESA), Iwould like towelcomeyou toour firstinternationalconference.

NESAwasfoundedin2004inordertointroduceand optimize surgical procedures and to spreadsurgical know-how to countries with minimal re-sources.Oneofthemainquestionswefaceishow

toadheretoahumanisticapproachandtheprinciplesofminimalisminaneraofevidence-basedmedicineandhightechnicaldevelopment.

TheNESADayspresentauniqueopportunitytoexchangeexperienceandknowledgewithspecialistsfromdifferentdisciplines.TheNESADays2006isthefirstofaseriesofinterdisciplinaryconferencesthataregoingtotakeplaceeachyearinadifferentcountry.DuringtheNESADays2006,youwillhavetheopportunitytomeet internationallyrenownedexpertsandlearntheirwayofthinking.Withparticipantsfrommorethan20countries,wecanlookforwardtoestablishinginternationalprofessionalconnectionswithgeneralsurgeons,gynaecologists,otolaryngologists,urologistsandanaesthesiologists.

Iwishallofyouafruitfulconferenceandhopethatmanyofyouwillremainincontactwithusandparticipateinourmultinationalsurgicalstudies.

Michael Stark MD President, The New European Surgical Academy

�

The Danish Surgical Society joined the NESA in2005.Weappreciate thecollaborationand thinkit will give rise to many fruitful discussions and,hopefully, common scientific projects. We findNESA’sideasconcerningthere-evaluationofsur-gical procedures in order to optimize, simplifyand standardize procedures very important. ThepresentNESADays2006willhopefullybeasigni-ficantsteptowardsthisgoal.

The NESA Days 2006 will be an excellent possibility for interdisciplina-ryexchangeandsharingknowledgeindifferentsurgicalareasaswellasanaesthesiology.Theveryimportanttopicofeducationandhowtoachie-vepracticalskillsinallthedifferentspecialitiesareanotherimportantfo-cus.The program contains presentations of many new surgical methods ingeneralsurgeryandgynaecologyalongwith theconnectiontomodernanaesthesia,specificallyaddressingtheincreasinguseofminimalinvasivetechniquesinallkindofsurgery.Wehope that this firstNESAmeetingwill serve as an appetizer for allEuropeandoctorstreatingpatientswithdisordersrequiringsomekindofsurgicalintervention.Wehopeitwillestablishabasisforinterdisciplinarydiscussionswiththepurposeofcreatingscientificstudiesthataimtoopti-mize,simplifyandstandardizethedifferenttreatmentmodalities,whichisoneoftheimportantgoalsoftheNESA.WehopethatyouwillenjoythemeetinginBerlin.

Svend Schulze, MD DMSc President, The Danish Surgical Society

10

WelcometotheNESADays2006Itgivesmeagreatdealofpleasure towelcomeyou to thismeeting,personallyandonbehalfoftheNewEuropeanSurgicalAcademy.

As surgeons we are all interested to refine andstreamline surgical techniques in order to betterservetoourpatients.ToparaphraseVictorGomel,

surgeryperformedotherthanfortraumaandreconstructiondemonstra-testheinability,indeedthefailure,ofmedicine.Therefore,whenweareobligedtoresorttosurgerywemust,wheneverpossible,useminimalac-cess andeffective techniques that are streamlined,bloodless and cost-effective.

Toachievethisaim,wehavetobeopen-minded,curiousandwillingtolearnfromothersurgeonsinourownaswellasotherdisciplines.Further-more,wehavetobeourowncriticsbyreviewingourcases,preferablythroughvideo,tonotetheunnecessaryorwrongstepsthatwehavemadeduringtheprocedure.Footballplayersdoit;whyshouldwenot?

This is the first congress of NESA. Please express your opinions freely,basedonyourexperienceandunderstanding.Tomakethecongressmorefruitful,Iencourageyoutobeactive,challengethespeakersandtheex-pertsandparticipateinthediscussion.Ialsoencourageyoutoparticipateinthesocialprograms,enjoyyouroldfriendsandacquirenewones.EnjoyBerlin–exploreitshistoric,culturalandartisticrichness.

Thankyouforyourparticipation.

Oktay Kadayıfçı MD Head, Ob/Gyn Department of the Çukurova University (Adana, Turkey); President, The Turkish Society of Feto-Maternal Medicine and Perinatology

11

We live in a time of regulated specialty trainingwhereoperative skillsarecatalogued inadditionto thenecessarybasic skills training. Impact fac-torsseemmore importantthanoperativeperfor-mance. Innovationsbecome importantonlyafteryear-long studies striving for evidence. It is unu-sualtoquestion“established”procedures.Basedonthiscaricaturedbackground,itnotonlymakessensetomovethefocustowardthedirectpatient-work,itevenprovesnecessarytodoso,especially

intheoperativegenre.

Howshallthingsproceed?Innovationsornewstandards?Returntotheestablishedonesorshifttowardsnewspheres?IamexcitedtofindoutwhatnewideastheinterdisciplinarymeetingNESADays2006maybringtoourprofession.

Klaus Vetter President, The German Society for Obstetrics and Gynaecology (DGGG)

1�

InternationalscientificcommitteeoftheNESADays2006

ZionBen-Rafael Israel

PeterBiro Switzerland

ChristophE.Broelsch Germany

GerhardBuess Germany

RabihChaoui Germany

GianCarloDiRenzo Italy

JacquesDonnez Belgium

MichelleFynes UnitedKingdom

WernerGrünberger Austria

AlbertHuch Switzerland

OktayKadayıfçı Turkey

LiselotteMettler Germany

NorAshikinMokhtar Malaysia

FarrNezhat USA

KyprosNikolaides UnitedKingdom

MarcPossover Germany

RudolfRoka Austria

ArieRosen USA

HerbertStark Austria

ErricoZupi Italy

1�

ScientificprogrammeoftheNESADays2006

Thursday,January19

20:00 Get-Togetherandregistration

Friday,January20

Room1

08:30 Welcomeaddress

PLENARYLECTURES09:00-09.30 Pastandpresentofgynecologiclaparoscopy,focus onhysterectomies Liselotte Mettler (Kiel)

09:30-10:00 Complicationsoflaparoscopicsurgeryingynecology Farr Nezhat (New York)

10:00-10:30 Computer-aidedsurgicalplanningandprocedures Albert Schaeffer (Bickenbach)

10:30-11:00 TheproteomeandtheMHC-peptidomeofhuman cancercells Arie Admon (Haifa)

11:00-11:30 Coffeebreak

11:30-13:00 State-of-the-artlectures Theroleofendoscopytoday Chairmen: F. Nezhat, Z. Ben-Rafael, M.Z. Papa

Urologicallaparoscopy(fromcuttingstonestominimal invasiveprocedures) Gralf Popken (Berlin)

Thecombinedlaparoscopicandvaginalapproachin gynaecologicalmalignancies A. Schneider, C. Köhler (Berlin)

Roleoflaparoscopyinovariancarcinoma Farr Nezhat (New York)

Endoscopictreatmentofgastrointestinalmalignancies M. Venturero, M.Z. Papa (Tel Aviv)

1�

Room2

11:30-13:00 State-of-the-artlectures Newdevelopments Chairmen: O. Kadayıfçı, W. Gruenberger, R. Robel

Minimallyinvasive,newtechniqueforthecreation ofaneovaginainpatientswithvaginalaplasia René Wenzl (Vienna)

Creationofartificialvaginawithanendoscopical procedure Werner Gruenberger (Vienna)

Innovativeconceptsandproceduresinpediatric endoscopicalsurgery

Klaus Schaarschmidt (Berlin)

Thelaparoscopicneuro-functionalpelvicsurgery M. Possover (Cologne), V. Chiantera (Neaples)

Room3

11:30-13:00 Organisationandqualitymanagement Chairmen: G.C. Di Renzo, T. Mansky, B. Stitz

TheFastTrackconceptincolonsurgery Albert Tuchmann (Vienna)

Economicaspectsofendoscopichernia repairinHelios-clinics Kai Witzel (Huenfeld)

Costbenefitsofgynecologicallaparoscopy G.C. Di Renzo, A. Mattei, S. Gerli (Perugia/ Florence)

Improvementofin-hospitalmortalityandother outcomeparametersbyqualitymanagement basedonadministrativemedicaldata Thomas Mansky (Fulda)

Parallelsbetweenairflightandsurgery Carsten Schmidt (Lufthansa)

Take-Homemessage Thomas Mansky / G.C. Di Renzo

13:00-14:00 Lunch

1�

Room1

14:00-16:00 State-of-the-artlectures Thefuture Chairmen: A. Tuchmann, K. Wagner, O. Rink

Realitiesofroboticsandpracticeofendo-scopic surgeryonvirtualandrealpatients Liselotte Mettler (Kiel)

Thetransperitoneallymphadenectomy A. Schneider, C. Köhler (Berlin)

Anesthesiaandthefutureoperativeenvironmentfor laparoscopicsurgery Klaus Wagner (Lübeck)

Focusedultrasoundtherapy:Uterinefibroids andbeyond Elizabeth A. Stewart (Bosten)

Anesthesiaforthe„new“patienthavinglaparoscopic surgery:5yearsfromnow Klaus Wagner (Lübeck)

Virtualrealityinsurgicaleducation Albert Schaeffer (Bickenbach)

Room2

14:00-16:00 State-of-the-artlectures Alternativestotraditionalmethods Chairmen: V. Gomel, M.Z. Papa, K. Witzel

Cryomyolysisandlaparoscopy Errico Zupi (Rome)

Importanceofwirelesscapsuleendoscopyfortargeted surgicalinterventioninsmallboweldiseases H. Hönicke, C. Rink (Aue)

Virtualsurgicaltreatmentofmalignancy-MR guidedfocusedultraso M.Z. Papa, Y. Inbar, A. Velaneu, S. Ayalon, D. Barsuck, M. Sareli, A. Yosipovich, Y. Kupilovich, A. Perl, B. Kaufman, R. Catane, D. Kopelman, A. Hannenel (Tel Aviv)

1�

Preliminaryexperiencewithtreatmentofboneandliver tumorswithMRguidedfocusedultrasound Jens Ricke (Berlin)

Laparoscopichysterectomy-Acomputer-generated 3-dimensionalanimationofasurgicalprocedure G. Slavka, R. Wenzl (Vienna)

Anaesthesiaforlaparoscopicprocedures Peter Biro (Zurich)

Room3

14:00-16:00 Theuseofendoscopyingynecology Chairmen: O. Kadayıfçı, E. Zupi, N. Samtaney

Laparoscopicassistedvaginalhysterectomy(LAVH)- Auniquemethodtoavoidunnecessaryabdominal hysterectomies Ralf Robel (Borna)

Comparisonoflaparoscopicandopenhysterectomy B. Stitz, C. Koch, A. Gaußmann, E. Schlothauer, U.B. Hoyme

Hysteroscopicendometrialresectionversuslaparos- copicsupracervicalhysterectomyformenorrhagia: Aprospectiverandomizedtrial Errico Zupi (Rome)

Laparoscopicdiagnosisofchlamydialsalpingitis U.B. Hoyme, U. Mahnert, A. Kentner (Erfurt)

Laparoscopicfollow-upofuterinescarandpost- cesareanadhesionwithandwithoutopenperitoneum A. Malvasi, A. Tinelli, R. Tinelli, G. Vittori, P. Scollo, O. Piccinni, C. Cavallotti (Bari)

Laparoscopicapproachtodermoidcysts:combined surgicaltecniqueandultrasonographicevaluationof residualfunctioningovariantissue Errico Zupi (Rome)

Aleaptowardthetopofthelearningcurvein gynaecologicendoscopyandepisiotomyrepair A.J. Schneider (Rotterdam)

1�

Take-Homemessage E. Zupi / R. Robel / U.B. Hoyme

16:00-16:30 Coffeebreak

Room1

16:30-19:00 Theuseoflaparoscopyinmalignancies Chairmen: A. Schneider, W. Gruenberger, T. Benhidjeb

Laparoscopicradicalnephrectomyinrenalcellcancer- Techniqueandoncologicalfollowupin170cases A.H. Wille, M. Tüllmann, J. Roigas, S. Deger, S.A. Loening (Berlin)

Onwardprogressincolorectalcancerby laparoscopicsurgery T. Benhidjeb, S. Anders, E. Bärlehner, M.W. Strik (Berlin)

Thelaparoscopictreatmentofcolorectalcancer Albert Tuchmann (Vienna)

Laparoscopicretroperitoneallymphadenectomy- Aroutinediagnosticorstagingmodalityinthe managementofstageInonseminomatoustetsiscancer A.H. Wille, S. Deger, J. Roigas, S.A. Loening (Berlin)

Ductoscopyandductoscopicbiopsy:Newperspectives forearlydiagnosisandminimalinvasivetreatmentof breastcancer M. Hünerbein, M. Raubach, B. Gebauer, W. Schneider, P.M. Schlag (Berlin)

Laparoscopicstagingofcervicalcancer M. Possover (Cologne), V. Chiantera (Neaples)

Laparoscopicmanagementofendometrialcancer Farr Nezhat (New York)

1�

Room2

16:30-19:00 Modificationoftechniquesinuse Chairmen: S. Schulze, G. Zografos, S. Meisner

Stressincontinence-Newideas Michelle Fynes (London)

EndoscopicplacementofSelfExpandingMetalStents- Firstchoicetreatmentofcolo-rectalobstruction: Techniqueandresultsfromasinglecenter S. Meisner, C.A. Bertelsen (Copenhagen)

Nonpalpablemammographicsolidtumorsofthe breast:Themammotomebiopsy G. Zografos, F. Zagouri, G. Filipakis, D. Kouloxeri, M. Tsakiri, G. Giannakopoulou, M. Kotsani, N. Pararas, A. Noni, J. Bramis (Athens)

Managementofscarringinendoscopicsurgery Arie Rosen (New Jersey)

Video-assistedairwaymanagement Peter Biro (Zurich

Nervesparing,totalmesometrialresectionof cervicalcancer Werner Mendling (Berlin)

Combinedlaparoscopiccholecystectomyand myomectomyatthesamepatient.Acasereport D. Stojanovic, D. Antic, B. Dakovic, M. Stojanovic, Dj. Lalosevic, P. Stevanovic (Belgrade)

Room3

16:30-17:00 Preventionofcomplicationsinoperativelaparoscopy Victor Gomel (Vancouver)

17:00-17:15 Extraperitonealendoscopicrepairofinguinalhernias Kai Witzel (Huenfeld)

17:15-17:30 Analternativetolaparoscopicallyassistedvaginal hysterectomy Michael Stark (Berlin)

1�

17:30-19:00 Roundtable:Fromsurgerytominimalinvasiveand non-invasiveprocedures Z. Ben-Rafael (Tel Aviv), M.Z. Papa (Tel Aviv), G. Popken (Berlin), Elizabeth A. Stewart (Boston), G. Buess (Tuebingen), M. Stark (Berlin), D. Maor (Tirat Carmel)

20:30 Culturalevent:TheComedianHarmonists/ Dinner

Saturday,January21

Room1

08:30-11:00 Advancesintechnology Chairmen: G. Buess, R. Chaoui, M. Iaccarino

Technologyandresultswiththeradiussurgicalsystem, asuturingdevicewithalldegreesoffreedom Gerhard Buess (Tuebingen)

The3-dimensional„InsectEye“laparoscopicImaging system-Evaluationofanoveltechnologybyapros- pectiverandomizedstudy Y. Kaufman, A. Sharon, O. Klein, D. Spiegel, R. Auslander, A. Lissak (Haifa)

Teachingforendoscopicsurgery,usingthe Tuebingen‘sTrainer Gerhard Buess (Tuebingen)

Clinicalultrasonography:Adecisivetoolingastroente- rologyandinabdominalsurgery Lucas Greiner (Wuppertal)

Intrauterineproceduresguidedbyultrasound Rabih Chaoui (Berlin)

Computercontrolledmultifunctionalrobot S. Devadurai, J. Maria Alen Dioney Biju, S.P. Sathappan (Chennai)

Take-Homemessage G. Buess / R. Chaoui / A. Schaeffer

�0

Room2

08:30-11:00 Theroleofendoscopyinurologicalsurgery Chairmen: G. Popken, D. Schulz, S. Jeffery

Thepastandfutureofendo-urology Gralf Popken (Berlin)

Resultsoftheendoscopiccorrectionofthevesico- ureteralrefluxwithconsiderationofcomplicated developments U. Friedrich, R. Vetter, K. Eichhorn, S. Feilmeier (Erfurt)

Laparoscopicdrainageoflymphocelesfollowingkidney transplantation–Easy,safeandgentle A. Paul, J. Treckmann, C.E. Broelsch (Essen)

Resectionoftheneurovascularbundleassecondstep procedureincaseofpositivemarginsafternerve- sparinglaparoscopicprostatectomy K. Kuhnt, D. Schulz, (Borna)

Laparoscopicpartialnephrectomyinrenalcellcancer- Resultsandreproducibilitybydifferentsurgeonsina highvolumelaparoscopiccenter A.H. Wille, M. Tüllmann, J. Roigas, S. Deger, S.A. Loening (Berlin)

Take-Homemessage G. Popken / D. Schulz

11:00-11:30 Coffeebreak

Room1

11:30-13:00 Endoscopyinotolaryngology Chairmen: T. Wilhelm, P. Mir-Salim, M. Harell

Endoscopicnasalsinussurgery:Anoverview Parwis Mir-Salim (Berlin)

Diagnosticprogressorfalseevidencebyin-vivocontact endoscopy-Acriticalpointofview Thomas Wilhelm (Borna)

�1

ComparingendoscopicandopensurgeryinENT Herbert Stark (Vienna)

EndoscopictreatmentofHypopharyngeal-Zenker dicverticulum Arie Rosen (New Jersey)

Endoscopicsurgeryofthelarynx Parwis Mir-Salim (Berlin)

Take-Homemessage P. Mir-Salim / A. Rosen / M. Harell

Room2

11:30-13:00 Theroleofendoscopyingastroenterology Chairmen: G. Buess, D. Amroch

Cliplesslaparoscopiccholecystectomy D. Amroch, G. Fanti, G.B. Chiara (Pordenone)

Gastricvolvulus-Laparoscopicgastropexy A. Rammohan, P. Balaji, S. Floret (Chennai)

TransanalEndoscopicMicrosurgery(TEM),technologies andresultsofendoluminalsurgery Gerhard Buess (Tuebingen)

Laparoscopiccholecystectomyanditshazards D. Amroch, G. Fanti, G.B. Chiara (Pordenone)

Anesthesiaforgastrointestinalendoscopyin2006 Dan Benhamou (Paris)

Take-Homemessage G. Buess / D. Amroch

13:00-14:00 Lunch

��

Room1

14:00-16:00 Workshop: Themultimodalpostoperativeanalgesiaandrecovery Peter Biro (Zurich), Dan Benhamou (Paris), Jochen Strauß (Berlin)

Room2

14:00-16:00 Creativethinking Chairmen: J. Dudenhausen, O. Kadayıfçı

Geneticsandfibroids:Thefutureisnow Elizabeth A. Stewart (Boston)

Minimalinvasivetreatmentofthoracolumbal burstfractures J. Schmidt, U. J. Teßmann (Berlin)

Endoscopicmeasuringofluminaldimensionsin caseofairwaystenosis Andreas Mueller (Gera)

Arthroscopicassistedtreatmentof intraarticularfractures Uwe-Jens Teßmann (Berlin)

Avoidingthepostnatalsurgerybyprenataltreatmentof fetalovariancysts Claudio Giorlandino (Rome)

Mammaryductoscopy G. Zografos, F. Zagouri, G. Fillipakis, N. Pararas, B. Oikonomou, M. Fotou, E. Stefanadi, J. Bramis (Athens)

Minimalinvasivetreatmentofthefracturedorbita Reinhard Bschorer (Schwerin)

16:00-16:30 Coffeebreak

��

Room116:30-19:00 Withandagainstthestream... Chairmen: M. Fynes, U. B. Hoyme

FromDrFreudtoDrViagra:Acenturyofcontroversies intreatingerectiledysfunction Ronald Virag (Paris)

Incidenceofpositivemarginsandearlypostoperative potencyoutcomesinnerve-sparingextraperitoneal laparoscopicprostatectomy K. Kuhnt, D. Schulz (Borna)

Monitoringprogressoflabour–Comparingtheuseof cervicometrytothetraditionalclinicalevaluation Dan Farine (Toronto)

VirtualEuro-Mediterraneanhospitalasatoolfor e-health Georgi Graschew (Berlin)

Cystoscopicintradetrusordysportinjectionsinpatients withrefractoryoveractivebladder S. Jeffery, R. Morley, M. Fynes (London)

Optimizinglivingdonorkidneytransplantation-Donor procedure A. Paul, J. Treckmann, C.E. Broelsch (Essen)

19:00 Finalcommentsandpriceawardforthe bestpresentation

��

��

Invitedspeakers

ArieAdmonDanBenhamouZionBen-RafaelPeterBiroChristophE.BroelschGerhardBuessRabihChaouiMichelleFynesClaudioGiorlandinoWernerGrünbergerLiselotteMettlerParwisMir-SalimFarrNezhatMosheZviPapaGralfPopkenMarcPossoverArieRosenKlausSchaarschmidtCarstenSchmidtJörgSchmidtAchimSchneiderElizabethA.StewartAlbertTuchmannKlausF.WagnerErricoZupi

��

��

Abstractsoftheinvitedspeakers

THEPROTEOMEANDTHEMHC-PEPTIDOMEOFHUMANCANCERCELLSArie Admon, MD Department of Biology, Technion-Israel Institute of Technology, Haifa, Israel

Proteomicstechnologiesarebeingusedincancerresearchwiththreemainobjectives.Thefirstinvolvesdevelopmentofnovelearlydetectiontoolsbycomparingtheproteinrepertoiresofcancercelllines,freshtumorsandserumofcancerpatients to thoseofhealthycontrols.Thiscomparativeproteomicsapproachishinderedbythecomplexityofthestudiedsamp-lesandthevariabilitywithinthepopulation.Anotherapproachisbasedonserololgical(orhumoral)proteomics.Thismethodologyisbasedoniden-tifyingtherepertoiresofproteinsfromcancercellsagainstwhichspecificantibodiesarepresentintheseraofcancerpatientandnotofcontrols.Theseantibodiescanbecomeusefulcancermarkers forconstructionofproteinarraysforrapidscreeningandthereforeearlydetectionofcancer.ThethirdappraochisaimedatanalysesoftheMHCpeptiderepertoiresofcancercellsforimmunotherapeuticsdevelopments.

MHC peptides originate from the degradation of both normal and di-sease-relatedproteinsexpressed incancercells.SincetherepertoireofMHCpeptidesmirrors thedegradationpatternsof thecellularproteins(thedegradome)ratherthantheproteomeofthecells,theirlarge-scaleanalysiscomplementstheproteomicsdatainsupplyinginformationaboutrapidlydegradingproteins.Rapidlydegradingproteinsincludebothde-fectiveribosomeproducts(DRiPs)andshortlivedproteins(SLiPs),whichcanpointtodefectiveproteinprocessingincancercells.First,thelarge-scaleidentificationofcancercellproteinswithemphasisonsmallcelllungcancrcinoma(SCLC)willbedescribed.Second,theanalysisoftheproteinsagainstwhichserological(antibody)responsesaredetectedinseraofcan-cerpatientswillbediscussed.Finally,IwilltalkabouttheidentificationoflargenumbersofMHCpeptidesfromhumancancercellswhosepeptidesincludesomethatarepossiblyderivedfromtumorantigens,DRiPsandSLiPs,andwhoseturnoverkineticswerealsodeterminied.

The large-scale analysis of MHC peptides began with transfection ofexpression vectors encoding different alleles of soluble HLA molecules(sHLA-A2,B7andCw4)intohumanculturedcancercells.Thesoluble(andsecreted)HLAmoleculeswererecoveredfromthecells‘growthmediumin

��

largeamounts.Thepeptidesandproteinswereidentifiedbytandemmassspectrometry (MS/MS) followedbyclusteringof theirMS/MSdatabyanewlydevelopedsoftwaretool(Pep-Miner).WecomparedrepertoiresoftheMHCpeptides(theMHCpeptidome)withtheproteomesofthesamecells.WhilemanyMHCpeptidesoriginatedfromrelativelyabundantlonglivedcellproteins,othersoriginatedfromproteinspreviouslyundetectedbyanyoftheproteomicsapproaches.CombiningtheproteomicsandtheMHC-peptidomedataoffersanewandinterestingpointofviewintothepossibledefectsofcancercells.

ANESTHESIAFORGASTROINTESTINALENDOSCOPYIN2006Dan Benhamou, MD Department of Anaesthesia and Reanimation, Hôpital de Bicêtre, France

Gastrointestinal endoscopy (GIE) has become quantitatively one of themostimportantinterventionalproceduresperformedtodayandhassigni-ficantlyincreasedtheworkloadofAnesthesiaDepartmentswithinthelasttwentyyears.Asanexample, inFrance,amongthe8millionanestheticprocedures performed each year, 15% are performed for GIE and it isevenmorenoticeablewhenitisremindedthatthisactivitywasalmostnonexistenttwentyyearsago(ClergueFetal,1999).Morethanhalfoftheseproceduresarecolonoscopicandmorethanonethirdaregastroduodeno-scopicprocedures.

Anesthesiafortheseproceduresfollowswell-definedpathwaysandmostoftendeep sedation/lightgeneral anesthesia is usedwhilepatients aremaintainedinspontaneousventilation.Hypoxemiaisgenerallyeasilypre-vented by nasal administration of oxygen. Retrograde choledochopan-creatographyrepresentsonlylessthan1/30ofallanestheticproceduresperformedforGIEbutitisamorecomplexandriskyprocedure.Becauseitisoftenalongprocedure(>45min)andthepatientispositionedinven-tralor lateraldecubitusposition, tracheal intubation is required inmostcases.Moreover,asradiographsaretakenduringtheprocedure,comple-te immobilization is required, explaining why the use of neuromuscularblockingagentsisnecessary.

Fortunately,thevastmajorityofGIEproceduresarescheduledcaseswhichlimittheincreasedanestheticriskassociatedwithemergencyprocedures.UpperintestinalhemorrhageisalmosttheonlysituationforwhichGIEisperformedinemergencysituationandbecauseitisusuallyashortproce-dureinhemodynamicallyinstablepatients,anestheticdrugsarenotusedandtheprocedureisperformedinawakepatients.

��

InFrance,apreanestheticvisitismandatoryforscheduledproceduresforwhichanesthesiaisrequiredandshouldbeperformedseveraldaysbeforetoensurethatoptimisationofthepatient’scondition,ifnecessary,canbedoneandthatproductionpressuredoesnotreducequalityandincreasestherisks.

Alargenumberoftheseprocedurescanbeperformedinambulatorypati-entsandthisseemsalogicalchoiceasmorethan50%ofthemareclassi-fiedASA1anddonotpresentwithanincreasedrisk.Descriptionoforga-nisationalconditionsrequiredforsafeandeffectivepracticeofambulatoryanesthesiaisoutofthescopeofthisabstractbutiseasytofindinmostanesthesiatextbooksorJournals(BrysonGLetal,2004,GuptaA2004).

Three main factors should be discussed as far as anesthesia for GIE isconcerned.

1-Anestheticdrugswhichareuseddifferdependingon theanestheticdepthrequired.a) Light sedation can be used by gastroenterologists (anesthesiologistsnotinvolved)forgastroscopyandmidazolam(oralofIV)isgenerallypre-ferred(TrevisaniLetal,2004).b)Generalanesthesia(includingtrachealintubationanduseofneuromus-cularblockingagents)isusedforretrogradecholedocopancreatography,although insome institutions,conscioussedation is therule (Mazzonetal,2005).c)Inmostcasesandespeciallyforcolonoscopy,deepsedation/lightgene-ralanesthesiausingpropofolisthemaintechniqueused(HeussLT,2004).Inmostpatiens,propofol isusedaloneas intraandpostoperativepainis limited (i.e.opioidsmaynotbeused [MoermanATet al, 2004]) andseveraltechniquesofadministrationarebeingused:incrementaltopupsadministeredbytheanesthesiologistasaresponsetopatientmovementreflecting pain, total intravenous anesthesia (TIVA) or target-controlledanesthesiawhilesomecentersadvocatepatient-controlledpropofolanes-thesiaandclaimthatitisworkswell(BrightEetal,2003).2-Hypoxemiaisaconstantriskassociatedwithanytypeofanesthesiabe-causeofanestheticdrug-inducedrespiratorydepression.Gastroduodeno-scopicandotherupperintestinalprocedureswhichrequireintroductionofthetubethroughthemouthincreasetherisksignificantlybecauseoflocalanesthesia(RistikankareMetal,2004)butalsoproportionnallytothesizeoftheendoscopictubewhichreducestheairwaycalibre.Thisriskexplainswhypulseoximetryismandatoryduringalltheseprocedures.Inthevastmajority of cases, spontaneous ventilation is maintained and adequateoxygenationisprovidedthroughnasaladministrationofoxygen.

�0

3-Anunsolvedandcontroversialproblemisrelatedtotherespectiveroleoftheanesthesiologist,thegastroenterologistandthenurse(-anesthetist)intheseprocedures(UlmerBJetal,2003,MotasDetal,2004,WaringJPetal,2003,RexDK,2004,KullingDetal,2003).InFrance,anesthe-siologists(andinmanyunitsnurse-anesthetists)areinvolvedandremainphysicallypresentduringtheseprocedures,thusensuringahighlevelofsafety.Gastroenterologistshowever,arenotalwaysconvincedthatanes-thesiologistsarenecessarytoensuresafety.Thestrongdesireexpressedby some gastroenterologists to manage themselves sedation for theseproceduresisreinforcedbytheshortageofanesthesiologistswhichexistsinmanyEuropeancountriesandmightreduceexpansionofthenumberofGIEprocedures.Theriskofseverecomplicationsanddeathstillremainsexplaining why many experts still consider that the involvement of ananesthetistinairwaymanagementandtheadministrationofintravenoussedationshouldbeactivelyconsidered(ThompsonAMetal,2004).

Clergue F, Auroy Y, Pequignot F, Jougla E, Lienhart A, Laxenaire MC. French survey of anesthesia in 1996. Anesthesiology. 1999 Nov;91(5):1509-20.

Bryson GL, Chung F, Finegan BA, Friedman Z, Miller DR, van Vlymen J, Cox RG, Crowe MJ, Fuller J, Henderson C; Canadian Ambulatory Anesthesia Research Education group. Patient selection in ambulatory anesthesia - an evidence-based review: part I. Can J Anaesth. 2004 Oct;51(8):768-81

Bryson GL, Chung F, Cox RG, Crowe MJ, Fuller J, Henderson C, Finegan BA, Friedman Z, Miller DR, van Vlymen J; Canadian Ambulatory Anesthesia Research Education group. Patient selection in ambulatory anesthesia - an evidence-based review: part II. Can J Anaesth. 2004 Oct;51(8):782-94.

Gupta A. Strategies for outpatient anaesthesia. Best Pract Res Clin Anaes-thesiol. 2004 Dec;18(4):675-9

Bonta PI, Kok MF, Bergman JJ, Van den Brink GR, Lemkes JS, Tytgat GN, Fockens P. Conscious sedation for EUS of the esophagus and stomach: a double-blind, randomized, controlled trial comparing midazolam with pla-cebo. Gastrointest Endosc. 2003 Jun;57(7):842-7.

Trevisani L, Sartori S, Gaudenzi P, Gilli G, Matarese G, Gullini S, Abbasciano V. Upper gastrointestinal endoscopy: are preparatory interventions or cons-cious sedation effective? A randomized trial. World J Gastroenterol. 2004 Nov 15;10(22):3313-7

�1

Mazzon D, Germana B, Poole D, Celato M, Bernardi L, Calleri G, Fant F, Bernard M, Lecis P, Costan Biedo F; Societa Italiana di Anestesia, Anal-gesia, Rianimazione e Terapia Intensiva. Conscious sedation during en-doscopic retrograde colangiopancreatography: implementation of SIED-SIAARTI-ANOTE guidelines in Belluno Hospital. Minerva Anestesiol. 2005 Mar;71(3):101-9.

Heuss LT, Inauen W. The dawning of a new sedative: propofol in gastrointe-stinal endoscopy. Digestion. 2004;69(1):20-6.

Moerman AT, Struys MM, Vereecke HE, Herregods LL, De Vos MM, Mortier EP. Remifentanil used to supplement propofol does not improve quality of sedation during spontaneous respiration. J Clin Anesth. 2004 Jun;16(4):237-43.

Bright E, Roseveare C, Dalgleish D, Kimble J, Elliott J, Shepherd H. Patient-controlled sedation for colonoscopy: a randomized trial comparing patient-controlled administration of propofol and alfentanil with physician-admini-stered midazolam and pethidine. Endoscopy. 2003 Aug;35(8):683-7.

Ristikankare M, Hartikainen J, Heikkinen M, Julkunen R. Is routine sedation or topical pharyngeal anesthesia beneficial during upper endoscopy? Ga-strointest Endosc. 2004 Nov;60(5):686-94.

Ulmer BJ, Hansen JJ, Overley CA, Symms MR, Chadalawada V, Liangpun-sakul S, Strahl E, Mendel AM, Rex DK. Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endo-scopists. Clin Gastroenterol Hepatol. 2003 Nov;1(6):425-32.

Motas D, McDermott NB, VanSickle T, Friesen RH. Depth of consciousness and deep sedation attained in children as administered by nonanaesthesio-logists in a children‘s hospital. Paediatr Anaesth. 2004 Mar;14(3):256-60.

Waring JP, Baron TH, Hirota WK, Goldstein JL, Jacobson BC, Leighton JA, Mallery JS, Faigel DO; American Society for Gastrointestinal Endoscopy, Standards of Practice Committee. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc. 2003 Sep;58(3):317-22.

Rex DK. The science and politics of propofol. Am J Gastroenterol. 2004 Nov;99(11):2080-3

��

Kulling D, Rothenbuhler R, Inauen W. Safety of nonanesthetist sedation with propofol for outpatient colonoscopy and esophagogastroduodeno-scopy. Endoscopy. 2003 Aug;35(8):679-82.

Thompson AM, Wright DJ, Murray W, Ritchie GL, Burton HD, Stonebridge PA. Analysis of 153 deaths after upper gastrointestinal endoscopy: room for improvement? Surg Endosc. 2004 Jan;18(1):22-5

VIDEO-ASSISTEDAIRWAYMANAGEMENTPeter Biro, PD Dr. med Department of Anaesthesiology, University Hospital Zurich, Switzerland

Inabout3%ofallintubationattempts,asufficientlygoodviewoftheglot-tiscannotbeachievedbymeansofdirectlaryngoscopy.Acarefulpreanae-stheticinterview,searchofpreviousanaesthesiarecordsandathoroughexaminationofthehead-neckregioncanrevealupto90%ofpossiblema-jorairwaydifficulties.However,thereremain10%ofunpredictabledifficultairwaysituations.Thewidelyacceptedgoldstandardtechnique,whichisthe elective awake fiberoptic intubation, can be applied under optimalconditionsandwithoutpressureoftime.Theunpredicteddifficultairwayischaracterisedbylackoftherightequipmentandexpertiseontherightspotattherighttime.Therefore,easytohandleandefficientmeansforprovisorysecuringtheairwayandinparticularformaintenanceofoxyge-nationarerequired.Videoassistedairwaymanagementcomprisesvideoassistedlaryngoscopyandvideoassistedintubation.Inbothcases,regularintubationequipmentisexpandedbyaneffectivevisualisationdevicethatdoesnotinterferewiththefamiliarhandlingofthebasictechnique,butadditionallyoffersanendoscopicviewoftheintubationpathway.Theout-putofthevisualsignalisabedsidedevicecontainingaflatscreenmoni-tor.Theinterfacesbetweentheimmediatelaryngoscopicequipmentandthemonitorisasmallsizeunitcontaininganultralongandnarrowflexiblefiberoptic,a lightsourceandaCCDcamera. Inorder toperformvideoassistedintubation,onemustinsertthelongfiberopticintotheendotra-chealtube,justlikeaconventionalmalleableguidewire.Forthispurpose,thefiberopticisenforcedwithawirefor30cmofitsdistalend.Thusitcanbemanuallybendedbytheuser,asheconsidersnecessary.Videoassistedlaryngoscopyisperformedwithalongfiberopticinsertedintothehandleofa speciallyprepared laryngoscope.The tipof thefiberoptic replacestheelectricbulbneartheendofthespatula.Thusthelightbroughtinbythefiberopticprovidesforthenecessary illuminationandtheviewfromthespatulaistransmittedtothevideocamerarespectivelytothemonitor

��

screen.Thebigadvantagewiththesetechniquesisthattheusermustnotfamiliarisehimselftoanyalternativemethod.Theintubationprocedurere-mainsasusuall,butoneisabletoviewsimultaneouslytheimagegenera-tedatthetipoftheendotrachealtube.Intheunpredicteddifficultairway,videoassisteddevicesarebyfareasiertohandle,sincetheyrequirenosubstantialmodificationofthefamiliarprocedures.Thus,theirapplicationhasa lowerpsychological threshold.Thedevice is fastassembled,easytocleanandtosterilize.However,videoassisteddevicesarenotsuitableforawakeapplication,thestyletcannotbesteeredfromaproximalport,areonlysuitablefororo-trachealintubationandthefiberoptichasnosuc-tionorworkingchannel.Inconclusion,thevideoassistedintubationandlaryngoscopyequipmentisnotintendedtoreplacetheflexiblefiberopticintheelectivedifficultairwaymanagement,whichisstillundisputedlythe„goldstandard“,buttheyaregoodsubstitutesfortheflexiblefiberopticintheunexpected,anaesthetiseddifficultairway.Ifindicated,thisequip-mentmaybemoreconvenientthantheflexiblefiberopticbecauseofeasyteaching,easylearning,simplerhandling,andbetteravailability.

ANAESTHESIAFORLAPAROSCOPICPROCEDURESPeter Biro, PD Dr. med Department of Anaesthesiology, University Hospital Zurich, Switzerland

Laparoscopicsurgerysupersedesmoreandmoretheopensurgicalaccessto theabdominalcavity.Variousadvantageshavebeenattributedto it,suchasbettercosmetic results, lesspostoperativepainandcomplicati-ons,bettercomfortandfasterrecovery,thusfinally leadingtoashorterin-hospitalstay.Concerninganesthesiawemustadmitthatsideeffectsofpneumoperitoneum (PP) interfere with vital functions, in particular withrespirationandhemodynamics.Theinsufflatedgaselevatesintraabdomi-nal pressure (IAP) and displaces the diaphragm to cranial. IAP is trans-mittedtothethoraciccavity,andthiscausesrisingairwaypressureanddecreasing total respiratory compliance. However, even though the PPhasnegativeeffectsonrespirationduringtheoperation,inthepostope-rativeperiod,strongbenefitshavetobeconsidered.Patientsundergoingopencholecystectomyascomparedwithlaparoscopicaccesshaveshownbyfarmoreimpairedlungfunctionparameters,suchasforcedexpiratoryvolumeinthefirstsecond(FEV1)(decreaseof55vs.30%),timedurationtill the recoveryof theaffectedFEV1 tobaseline (9.5 vs. 5days),peakexpiratory flow on the second postoperative day (50 vs. 25%) and thefrequencyofpostoperativeatelectasis (90vs.40%).Only the functionalresidualcapacityreductiononthefirstpostoperativedaywasmoreexpli-

��

citinpatientswithlaparoscopy(20vs.34%).Thereareadditionaleffectscausedbyreabsorptionofcarbondioxide(CO2) leadingtohypercarbiaand acidosis. If the patient is breathing spontaneously, a rising PaCO2directly leads to increase thealveolar ventilationas a first line counter-measure,followedbyenhancedrenalsecretionofacidiccompoundsandreabsorptionofbicarbonate.However,inmostcasescontrolledventilati-onisapplied,andtheanesthetisthastoadaptventilationpatternsinordertomaintainnormocapnia(whichmaynotalwaysbeachievedcompletely).Inpregnantwomenundergoingnon-obstetricsurgery,PPexertsnegativeeffectsonuterinebloodflowandoxygensupplyforthefetus.However,consequencesaffectingtheanesthesiologicalapproachhavetobeeva-luatedonan individual scale.Eventually, anopen surgicalprocedure inneutralhorizontalpositionshouldbeconsidered.Cholecystectomyisthemost often performed non-obstetric surgical intervention in pregnancy.Meanwhile50%ofcasesareperformedinlaparoscopicmode.However,surgerybeforethe20thweekofgestationbearsaslightlyelevatedriskforpretermbirth.Besidethis,thereisnofurtherevidenceforanydifferenceinmalformationfrequencyinopenvs.laparoscopicsurgery.Generallyspo-ken,onecannotstateacontraindicationforlaparoscopicsurgeryinpreg-nancyasamaterofprinciple. In themorbidobesepatient,amarkedlyhigherrateofcomplicationsandthenecessityofalongerin-hospitalstayhastobeexpected.However,ascomparedtoopensurgery,laparoscopicprocedurespresentlessproblemswithwoundhealing,andshowalowertendencyforburstabdomen.Thesepatients,inparticularbenefitfromanearlymobilizationandearlydischargefromthehospital.Laparoscopicsur-geryandtheappliedanestheticproceduresarenotfreeofcomplicationsandundesiredsideeffectssuchas,aspirationofgastriccontent,inadver-tentsecondaryunilateralbronchialendotrachealtubedisplacement,car-bonmonoxidepoisoning,surgicalemphysema,bleeding,pneumothoraxandpneumomediastinum.

LAPAROSCOPICDRAINAGEOFLYMPHOCELESFOLLOWINGKIDNEYTRANSPLANTATION-EASY,SAFEANDGENTLEPaul A, Treckmann J, Broelsch CE Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany

A lymphocele following kidney transplantation can congest the urinaryoutflowofthekidney.Asymptomaticlymphoceleoccurswithanincidenceof5%afterkidneytransplantation.

��

Traditionally,post transplant lymhoceles aredrainedbywidelyopeningthe wall connecting the intraperitoneal cavity to the lymphocele cavity.This procedure implicates a re-exploration of the wound with potentialproblemofwoundhealinginimmunocomprimizedpatients.

Laparoscopyallowstofenestratethelymphoceleintotheabdominalcavi-tywithaminimalintraoperativetrauma.Theprocedureiseasy,fastandinmostcaseswithoutinconvenienceforthepatients.Theapplicationoftheendoscopicultrasoundallows toperform laparoscopic fenestrationalsoinmostofthepatientswithunfavourablelocationsofthelymphocelelikelowerpoleofthekidneybesidetheureterandthevessels.

OPTIMIZINGLIVINGDONORKIDNEYTRANSPLANTATION-DONORPROCEDUREPaul A, Treckmann J, Broelsch CE Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany

Livingdonorkidneytransplantationhasbeensuccessfullyperformedsince50yearsinanopen/conventionaltechnique.Theidealdonorprocedureshouldbarelyshowcomplications,shouldbelittlebotheringandshouldhavenolongtimemorbidity.Fortheopenproceduredifferentaccessesweredeveloped:laparotomywithmedian,paramedian,transverseincisi-onsandretroperitonealaccesseswithsubcostal,pararectalandflankin-cisions.

Thefirstlaparoscopicdonorprocedurewasperformedin1995byRatner.Fortheseprocedures,differentmodesofhandlingmethodimmanentpro-blemsappearintheliteraturelikecompletelaparoscopic,handassistedandroboterassistedoperations.

Laparoscopic procedures seem to reduce operative trauma resulting inearlierrecovery,lesspain,lessfatigueandlesswoundrelatedmorbidity.Nevertheless,highqualitycontrolledtrialscomparinglaparoscopicproce-dureswiththe„best“conventionalmethoddonotexist.

Laparoscopicdonornephrectomieshaveatleastalongerlearningcurvethanopenproceduresmakingitdifficulttorecommendthisoperationforlowvolumecentres.

��

Competingthepotentialadvantagesoflaparoscopicprocedures,thepro-cessesinconventionaldonoroperationswereoptimizedwithmodernpe-rioperativeanesthesiologicandpainmanagementandothercomponentsof„fasttrack“rehabilitationinsurgery.

Theresultsofmorethan150livingdonoroperationswithdifferenttechni-queswillbepresented.

THEPRENATALTREATMENTOFFETALOVARIANCYSTSAVOIDTHEPOSTNATALSURGERYGiorlandino C*, Bagolan P**, Nahom A**, Coco C*, Mobili L*, Brizzi C*, Mangiafico L*, Spanò G*, Aleandri V** **Artemisia Medical Group, Department of Maternal Fetal medicine, Rome, Italy ** Ospedale Babin Gesu, Rome, Italy

PURPOSE:Toevaluateiftheprenatalaspirationoftheovariancystimprovestheout-comeandavoidsthetraumaticpostnatalsurgery,astatisticalanalysistocalculatethecut–offforthesizeofthelesionwasperformed.Theauthorsevaluatedtheoutcomeofsimplefetalovariancystsafterprenatalaspira-tionandconsideredcriteriaforthisprocedure.

BACKGROUND:TheOvariantorsioncausingthelossofanovaryrepresentsthemostcom-moncomplicationoffetalovariancysts.However,criteriaforprenatalde-compressionstillneedtobeevaluated.Previousexperienceoftheauthorsshowedthatlargesimplecystshaveapooroutcome,whereaspreliminaryattemptsoftheir„inutero“aspirationwereallsuccessfulanduneventful.

METHODS:Thisprospectivestudyincludes109ovariancysts(82simple,42showingtorsion)diagnosedin122fetusesfromJune1992toJune2005,andfol-lowedupuntilspontaneousresolutionorsurgery.Prenatalaspirationwasperformedinthecaseofsimplecysts>/=5cmindiameter.

Theoutcomeofthesecystswascomparedwithaseriesofsimilarcystsnotaspiratedintheauthors’previousstudy.Theoutcomeofsimplecystslessthan5cmandcystswithaprenatalultrasoundappearanceoftorsionalsowasevaluated.

��

RESULTS:Prenataldecompressionwasperformedwithoutanycomplicationsin24cases:1220regressedsubsequently;2showedtorsionpostnatally.Thisoutcomeissignificantlybetterthanthatofsimilarcystsnotaspiratedintheauthors‘previousstudy.

Amongthe58simplecystslessthan5cm,44resolvedspontaneously;14hadcomplications,12ofwhichshowingtorsion.Amongthe58cystssho-wingtorsion24requiredoophorectomy;15spontaneouslydisappearedatultrasound,oneofwhichrequiredsurgeryforintestinalobstructionse-condarytoadhesionofanecroticovary;onepatientwaslostofthefol-low-up.

CONCLUSIONS:Prenatalaspirationofovariancystsappearseffectiveandsafe:a„cutoff“of4cmistorecommend.Cystswithultrasoundpatternoftorsionpersi-stingpostnatallyrequiresurgery;optionsfortheirmanagement,whenso-nographicallydisappearingandasymptomatic,needtobeinvestigated.

CREATIONOFARTIFICIALVAGINA-ANENDOSCOPICALPROCEDUREWerner Grünberger, MD Semmelweiß-Klinik, Vienna, Austria

Mayer-Rokitansky-Kuester-Hauser-Syndromisaveryrarecongenitalmal-formationwith an incidence rateofonlyone in 10000newborns. ThismeansthatinAustriathereare8andinGermany80girlsborneachyearwiththiscondition.Morethan30differentmethodstocorrectthismal-formationaredescribedintheliterature.IntheSeventiesProf.Vecchiettiinvented a simple procedure, where the skinof theperineum is pulledbetweenbladderandrectum,tocreateanartificialvagina.

Since1979Ihavebeenverysuccessfulwiththisprocedureandhavemo-difiedittoanendoscopicapproach.AsofnowIhavetreated244caseswithpatientscomingfrommynativeAustriaandmanyforeigncountries.WiththeuseofsomenewlyinventedinstrumentsandnumeroussurgicalimprovementsIachievedanearzeromorbidity.Cosmeticandfunctionalresultsareperfect.Theprocedurewillbeshowninavideotape.

��

PASTANDPRESENTOFGYNECOLOGICLAPAROSCOPY,FOCUSONHYSTERECTOMIESLiselotte Mettler, MD Department of Obstetrics and Gynaecology, Campus Kiel, University Hos-pitals Schleswig-Holstein, Germany

Twentyyearsafterthefirstdescriptionofvaginalhysterectomywithlapa-roscopicassistancebyKurtSemmin1984and16yearsafterthepublica-tionoftheso-calledlaparoscopicassistedvaginalhysterectomy(LAVH)byHarryReichin1989,itisabouttimetoreviewandevaluatetherealbe-nefitsoflaparoscopichysterectomy.Althoughlaparoscopicsurgeryiswellacceptedbygynaecologistsworldwideforthetreatmentofcertaingynae-cologicalconditions,laparoscopichysterectomyinGermany,andprobab-ly worldwide, is still only performed by a few specialists. Highly skilledsurgicaltechniques,longeroperatingtimeandexpensivetechnologyaresuggestedtobethedeterringfactors.Laparoscopichysterectomy,initsdifferentformsisanattractiveandsafeprocedureforthemanagementofbenigngynaecologicalconditionsandmanyauthoritiesrecommenditsuseonalargerextent.Ontheotherhandinouropinion,theuseoflaparosco-pichysterectomyforoncologicalindicationsisstillcontroversial.Extensiveexperienceofover15years,inpractisingandteachingvariousformsoflaparoscopichysterectomy,namely, laparoscopicallyassistedvaginalhy-sterectomy(LAVH),total laparoscopicvaginalhysterectomy(TLVH),clas-sicintrafascialsupracervicalhysterectomy(CISH)andlaparoscopicsupra-cervicalhysterectomy(LSH)hasledmetothefirmconclusionthatthesetechniquesareadvantageoustopatientsifperformedfortheappropriateindication. Inparticular,subtotalorsupracervicalhysterectomy,withthecervixremaininginitsplace, isassociatedwithfewercomplicationsandavery favourableoutcome for thepatient.Radical laparoscopicvaginalhysterectomy(RLVH),thelastvariantinourexposé,isonlysuccessfulinanexpert’shands.Thesurgicaltechniquesofthesevarietiesoflaparoscopichysterectomieswillbedescribedandillustratedinthislecture.

REALITIESOFROBOTICSANDPRACTICEOFENDOSCOPICSURGERYONVIRTUALANDREALPATIENTSLiselotte Mettler, MD Department of Obstetrics and Gynaecology, Campus Kiel, University Hos-pitals Schleswig-Holstein, Germany

Toprovidethevirtualenvironment inatrainingsystemfor laparoscopicsurgery,arealistic3-Drepresentationoftheanatomicsitusisderivedfrom

��

2-Dmedicalimagedatausingimagingalgorithmsandvisualisationtechni-ques.Thus,anintuitivehandlingoftheinstrumentsisguaranteedandthesurgeonisabletoperformendoscopictechniquesonthevirtualsitus.

TheendoscopictrainingsystemdevelopedattheKarlsruheResearchCen-treinco-operationwiththeDepartmentofObstetricsandGynaecology,CampusKielisnamed“VSOne”.Theminorpelviswiththegynaecologicalorgans canbe simulated in a virtual environment.Bymeansof realisticuserinterfacethegynaecologistisabletograsp,coagulate,cut,introducenewinstruments,suture,applyclips,initiatebleeding,stopbleedingandpushasidetheintestines,allinarealisticsimulationscenario.

In addition to conventional laparoscopy and hysteroscopy training me-thods,itisnowpossibletoofferdoctorsavirtualtrainingsystemformi-nimallyinvasivesurgerywitharealisticuserinterface.Methodsandtoolsfortherealisticmodellingofdeformableobjectsandsimulationofsurgicalinteractionsaretohand.Acapabilityscorecanbedrawnupforeachtrai-nee.Visualeffectssuchasactivedeformableobjectsandparticlesystemsforfluidsimulationenhancethesimulationrealism.

VirtualRealitySimulationVirtual realitybasedsurgical simulationsystemswillbecomeevenmorerealisticinthefuture.Theywillbeintegratedintomultimediateachingandtrainingenvironmentsandallsurgicaldisciplineswillbecovered.Trainingonhumancadaversisstillanalternativebutthisisoftenmoredifficultthanworkingonthevirtualsitus.

RoboticCameraHoldingArmsTherearemanydifferenttypesofroboticcameraholdingsystems.AESOP(AutomatedEndoscopicSystemforOptimalPositioning)withhand,footor voicecontrol, received the robotof theyearaward2000 inmedicalapplication. The surgeon can direct the articulated metal arm by voicecontrol.Thelaparoscopecanbemovedinanydirection-left,right,up,down,forwardorbackward.Inaddition,laparoscopicviewscanbekeyedinforreturnvisitsbyusingthememoryfeaturewhichisavailableforthreepositions.AESOPallowsthesurgeontousebothhisarmstocontroltheinstruments. Itenablesatremor-free,voice-controlledmovementofthecamera.

TheZeussystemusesthreerobots,oneforcameramovementandtwoforroboticinstrumentation.Inadditiontothevoice-controlledmovementoftheinstruments,alldataareregistered.Anumberofcompaniesofferintelligentoperatingroomsystems:

�0

daVinciSurgicalSystemUsingthedaVinciSurgicalSystemitispossibletooperatewiththelookandfeelofopensurgery,performingcomplexsurgicalmanoeuvresthrough1cm ports in a sitting position with a so-called Surgical Immersion tech-nology.Theeyesandhandsofthesurgeonarecompletelyimmersedinthepatient.True-to-life,3-DvisionandinstinctiveoperativecontrolmakecomplexMISproceduresfeellikeopensurgery.

The surgical revolution initiatedby thedaVinciSurgicalSystemenablessurgerytobeperformedwithunprecedentedprecisionandcontrol.TheimmersioninthepatientbylookingintothedaVinci™hassofaronlybeenpractisedinafewcentres,mainlyinheartandgeneralsurgery.Resultsonpatientsareminimal,butfascinating.

ENDOSCOPICNASALSINUSSURGERY:ANOVERVIEWParwis Mir-Salim, PD Dr. med Klinikum im Friedrichshain, Berlin, Germany

Endoscopicsinussurgery isaprocedureinwhichthesurgeonexaminesthenasalcavityandthedrainagewaysoftheparanasalsinuses.Usingsta-teoftheartendoscopesandmicrosurgicalinstruments,abnormalandob-structivetissuesarethenremoved.Inmostcasesthesurgeryisperformedendonasally,leavingnoexternalscars.Milddiscomfortandnasalsecretionarecommonpostoperatively.

Whereas,inthepast,attentionhasoftenbeendirectedtowardstheremo-valofallsinusmucosafromthemajorsinuses,theendoscopicapproachreliesontheprinciplethatsinusdiseaseisreversibleiftheunderlyingob-structioncanbeidentifiedandcorrected.Acarefuldiagnosticworkupisthereforeimportantandconsistsofexamination,CTscansofthesinuses,rhinomanometry,inspecialcasesnasalcytologyandsmelltesting.Surgeryisusuallyrecommendedonlyaftermedicaltherapyhasfailed.

Theadvantageofendoscopicsinussurgeryisthephilosophicalrecogniti-onthatthesurgicalgoalistoopenthenaturaldrainagechannels,therebyrestoringnormalphysiologicfunction.Thisdiffersgreatlyfrompastpro-cedures,whichwereablativeanddestructive.Otheradvantagesoverpastsinussurgeriesare:diminishedpostoperativediscomfortbyapplicationofresorbablenasalpackingsanddecreasedbleedingriskbecauseoftis-suesparinginstruments.Thiscontributestoashorterrecoveringtimeandmostimportantly,a80%successrate.

�1

Thedifferentsurgicalstepsofendoscopicsinonasalsurgeryaredemon-strated.Theanatomyhasoftenagreatvariety.Theethmoidroofispartoftheanteriorskullbase,thesphenoidsinusislocatedwithinthecentralskullbase.Potential surgicalcomplications includebleeding,orbitalhe-matoma,swelling,endonasalsynechiaorinfection.Rarecomplicationsareintracranialentryandcerebral injury.Usingendoscopesandmicroscopemajorcomplicationssuchasvisualloss,CSFLeaksorInternalCarotidinju-ryarefortunatelyrare.

Endoscopic sinus surgery is nowadays a well established procedure. InfutureNavigationsystemsandpoweredinstrumentswillimprovetheout-come.

ENDOSCOPICSURGERYOFTHELARYNXParwis Mir-Salim, PD Dr. med Klinikum im Friedrichshain, Berlin, Germany

Endoscopic procedures of the larynx are well established for the treat-mentofbenignlaryngealdiseasessinceseveraldecades.Incasesofma-lignantlarynxtumorstotaloropenpartiallaryngectomieswerecommonmethods.Theseproceduresrequireatracheotomyandfrequentlyleadtolongtermaspirationandhoarseness.

Inthe80‘stheendoscopictransorallaserresectionoflaryngealcarcinomaswas introduced. Further technical development has this method nowa-daysoptimizedwithinthetherapyoflaryngealmalignincies.Thegoalinconservationlaryngealsurgeryistopreservemaximumlaryngealfunctionwithoutcompromisingthecurerate.Comparedtoanyotherprocedurethis surgerymaintainsphysiologic speechand swallow functionwithouttheneedforapermanenttracheostoma.

Similartotheconventionalsurgerycompleteremovalofallmalignantdi-sease shouldbeachievedwhilepreserving the4basic functionsof thelarynx: deglutition, respiration, phonation, and airway protection. Re-gardlessofthespecificconservationlaryngealprocedure,afewkeyprin-ciplesmustberespected.

Adiagnosticendoscopyenablesthesurgeontoassesstumorextensionandexpositionthatdetermineseligibilityfororganpreservationsurgery.Furthermore, it isvitally important toassess subglotticgrowth.At leastthecricoarytenoidunitisthebasicfunctionalunitofthelarynx.Aslongas

��

oneunitcanbepreserved,thepatientisapotentialcandidatefororganpreservationlaryngealsurgery.Thecurrentliteratureisspecifiedasametaanalysisandprovesthesuita-bilityofthismethodinthetreatmentofglotticandsupraglotticTis-T2stages.Thebordersofthetransorallasersurgeryofthelarynxarepointedoutonthebasisneweststudies.Severalclinicalexamplesweredemon-strated.

COMPLICATIONSOFLAPAROSCOPICSURGERYINGYNECOLOGYFarr Nezhat, MD FACOG Division of Gynecologic Oncology, Mount Sinai Medical Center, New York, USA

Complicationsof laparoscopic surgery canbedivided into twogeneralcategories.Thefirst includesthosecomplications,whichare inherenttolaparoscopyitself,regardlessofthespecificprocedurebeingperformed.Theseincludecomplicationssuchassubcutaneousemphysemaorlacera-tionoftheabdominalwallandtrocarinjuriestoinferiorepigastricvessels,the bowel or major retroperitoneal vessels. The second group of com-plicationsincludesthosethatareinherenttoaspecificprocedurebeingperformed.

InthisreviewweuseLaparoscopic lymphadenectomyasanexampletodiscusssomeofthesecomplications.

Lymphnodestatusisthemostimportantprognosticfactoringynecologiccancerandsurgical removalofpelvicand /orPara-aortic lymphnodesforhistologicassessment, isan integralpartof staging forgynecologicmalignancies.Additionally, removalof thebulky lymphnodesmayhavetherapeuticbenefit.

TechnicallythereareseveralbenefitsoflaparoscopicapproachtopelvicandPara-aorticlymphadenectomy.Thelaparoscopeprovidesa7-10foldmagnificationoftheoperativefieldallowingidentificationofsmalltributa-ryvessels.Further,thepneumoperitoneumfacilitatesthedevelopmentofpelvicspacesanddecreasesvenousoozing,therebymaintainingacleanoperativedissectionwithgoodvisualizationofnodalbundles.

1-Vascular injuries- Inaseriesof laparoscopic lymphadenectomy,sevenoutofninevascularcomplicationsoccurredastheresultoftrocarinjury

��

totheanteriorabdominalwallvasculature.Potentialvascularcompromisespecifictopelviclymphadenectomyincludesinjurytotheobturator,inter-naliliac,externaliliac,orthecommoniliacvessels.VesselsatriskforinjuryduringPara-aorticlymphadenectomyincludetheaortaandvenacava,aswellasthecommoniliac, inferiormesenteric, lumbar,ovarian,andrenalvessels.

2-Genitourinaryinjuries-Cystotomyduringtrocarinsertion,adhesiolysisordissectionwithEndoscopicscissorswithorwithoutelectrocauteryhasbeendescribedasacomplicationoflaparoscopiclymphadenectomy,alt-houghnotspecifictothisprocedure.Pelviclymphadenectomyplacestheureteratriskforsharp,crushorthermalinjury.ThelumbarportionoftheureterisatriskduringPara-aorticlymphadenectomy.

3-Abdominalwallmetastasesandperitoneal tumordissemination-Ab-dominalwallmetastases,alsocalledportorwoundsitemetastases,havebeenreportedafterbothlaparoscopyandlaparotomy.Theincidenceofthesecomplicationshasbeen1%afterlaparotomyand1-3%afterlaparo-scopy.Portsitesarecontaminatedduringtumorextractionorwithdrawalofcontaminatedports.Theriskofcontamination ishigher ifabdominalinsufflationislostduringtumorextractionorportwithdrawal.Topreventthiscomplication,removalofallspecimensusinganendobag,removalofallportswhiletheabdomenisstillinsufflatedandimmediatelocaltreat-mentofthecontaminatedportswithacytotoxicagent,ismandatory.4-Complicationsrequiringlaparotomy-Complicationsresultinginlaparo-tomyhavebeenrelatedtodamagetotheureter,bladder,bowelandva-scularstructures.Theincidenceofconversiontolaparotomyin449casesfromfourlargestudieshasbeenreportedtobe9.3%.

LAPAROSCOPICMANAGEMENTOFENDOMETRIALCANCERFarr Nezhat, MD FACOG Division of Gynecologic Oncology, Mount Sinai Medical Center, New York, USA

Endometrialcanceristhemostcommonmalignancyamongwomeninthedevelopedworld,withanestimated40,880casesand7,310,000deathsin2005.Currently,thestandardtreatmentinvolvingremovalofuterus,tu-besandovariesandsurgicalstagingisperformedvialaparotomyatmostcentersaroundtheworld.

��

Sinceitsintroductionintheearly1990s,laparoscopicsurgeryforthesta-gingandtreatmentofendometrialcancerhasbecomeawidelyacceptedalternativetothetraditionallaparotomy.Intheabsenceoflarge-scaleran-domizedcontrolledtrialstovalidatethebenefitsoflaparoscopyoveropensurgeryfortheprimarymanagementofendometrialcancer,thefeasibilityandsafetyofthelaparoscopicapproachhavebeenestablishedfromse-veralcohortandcase-controlstudiesintherecentliterature.Theresultsofprospectiveseriesandsmallrandomizedtrialscomparinglaparoscopyandopenproceduresinwomenwithendometrialcancershowedthatthelaparoscopicmanagementallowsareductionofperioperativecomplicati-onsandafasterrecovery,withsimilaroverallanddisease-freesurvival.

ROLEOFLAPAROSCOPYINOVARIANCARCINOMAFarr Nezhat, MD FACOG Division of Gynecologic Oncology, Mount Sinai Medical Center, New York, USA

Approximately80%ofwomenwhohaveovariancancerarediscoveredwithadvanceddisease(stageIIIorIV),whiletheremainingpatientspre-sentwithstageIorIIdisease.Patientswhoappeartohavediseaselimitedtooneovary(stageIa)requireafullsurgicalstagingprocedure.Thisinclu-desaspirationandcytologicassessmentofallpelvicandabdominalfluid,pelvicandpara-aorticlymphnodesampling,infracolicomentectomy,andbiopsiesof theperitoneum fromthecul-de-sacs,paracolicgutters,anddiaphragms.One-thirdofthepatientswhoappeartohavediseasecon-finedtotheovaryareupstagedafterasurgicalstagingprocedure.Theincidenceofpositivelymphnodesisashighas24%instageIdisease.39Anationalcooperativestudyfoundthat28%ofpatientsthoughttohavestageIdiseasewereupstagedaftercompletesurgicalstaging.Inadequatestagingcanleadtoimproperpostoperativetherapyandapoorerprogno-sis.

Thestandardpreoperativeevaluationincludesahistoryandphysical,pel-vicexamination,aPapanicolaousmear,completebloodcount,liverprofi-le,andchestx-ray.Intravenouspyelography,bariumenema,colonoscopy,andgastrointestinalseriesareutilizedasindicatedbythesymptomsandphysicalexam.Ultrasoundcanbehelpful inevaluatinganadnexalmassforcysticandsolidcomponents,butthefindingsarenotdiagnosticofthemalignancyofamass.41,42CTscansarehelpfulinpreoperativeplanningforpatientswithanupperabdominalmassorlivermetastasisinasympto-maticwomenandthosewithnormalliverfunctiontests.

��

The standard therapy for a histologically confirmed ovarian cancer is acytoreductiveoperationtoeliminateallgrossdisease.Thisprocedurege-nerally includes a total abdominal hysterectomy and bilateral salpingo-oophorectomy,aninfracolicortotalomentectomy,andpelvicandpara-aortic lymphnode sampling.Multiple retrospective studieshave shownthatsurvivalisimprovedifpatientshavenoresiduallesionslargerthan2cmindiameter.Althoughnoprospectivestudiesrandomizingpatientstoprimarysurgeryorchemotherapyhavebeenconducted,atrialofintervalcytoreductionafterthreecyclesofchemotherapyrevealedasurvivalbe-nefitforpatientswhohadanoptimalresectionoftheirdiseasecomparedwithpatientswhodidnot.

LaparoscopicStagingTheuseoflaparoscopytosurgicallystageapatientwithstageIorIIovari-ancancerhasbeenreported.Pomelandcoworkersdescribed10patientswhounderwentcompletesurgicalstagingforpresumedstage Iovariancancer. These procedures included peritoneal washings, peritoneal andovarian biopsies, infracolic omentectomies, and pelvic and para-aorticlymphadenectomies.Amedianofsixpelvicandeightpara-aorticnodesfromeachhomolateralchainwasobtained.Nointraoperativecomplicati-onsoccurred.Onepatienthadapostoperativepulmonaryembolism,andanotherrequiredlaparotomyforhemoperitoneumsecondarytobleedingfromthevaginalcuff (twopatientshad laparoscopicallyassistedvaginalhysterectomies).

Second-LookLaparoscopyAlthoughtheindicationforsecond-lookoperationsinpatientswithova-riancancerafterchemotherapy isdebatable, laparoscopycansafely re-placelaparotomyinmostcases.Asmanyas50%ofpatientswithnegativesecond-lookprocedureswillhavearecurrence.Improvementsinlaparo-scopicequipmentandskillsincreasedthesensitivityandsafetyofsecond-lookprocedures.

VIRTUALSURGICALTREATMENTOFMALIGNANCY-MRGUIDEDFOCUSEDULTRASOUNDPapa MZ, Inbar Y, Velaneu A, Ayalon S, Barsuck D, Sareli M, Yosipovich A, Kupilovich Y, Perl A, Kaufman B, Catane R, Kopelman D, Hannenel A Chaim Sheba Medical Center, Tel Hashomer & Tel Aviv University, Israel

Theuseofhighenergyfocusedultrasoundwaves(FUS)todestroytumortissue will be described. High energy FUS causes cell death by raising

��

thetemperatureofthetreatedtumorhighenoughtocreatecellproteindenaturation,cellmembranedamageandcelldeath.Thetissuedestruc-tionisatthefocuspointoftheultrasoundbeamswithextermlyhighheatgradientsbetweenthetargetcellsandsurroundingtissue,thustheeffectoftheFUSenergyisconcentratedatthetarget,leavingthehealthytissuesafe.ThecombinationoftheFUSgeneratorwiththeMRallowsaccurateplanningofthetreatment,realtimeimagingandheatmeasurementsinthetreatedtissue.OurexperimentalexperienceinhumansandanimalmodelsusingFUSinthebreast,uterus,boneandliverwillbedescribedandthefuturepoten-tialofthistypeoftumorablationandothertypesoftumorablationwillbediscussed.

ENDOSCOPICTREATMENTOFGASTROINTESTINALMALIGNANCIESMoris Venturero MD, Moshe Zvi Papa MD Department of Surgery and Surgical Oncology, The Chaim Sheba Medical Center, Tel Hashomer, Israel

Minimally invasive, laparoscopicallyassistedsurgerywasfirst introducedinearly1990sforbenignandmalignantcolorectalconditions.Acceptanceoflaparoscopyforthemanagementofoncologicaldiseasehasbeenslowduetothe increasedcomplexityofthetechnique,requirementoftech-nologicaladvances,andfearsfortheoncologicalsafetyoftheapproach.Like the laparoscopic approach forotheroperations,minimally invasivecolectomyshowedpotentialbenefitsof improvedshort-termoutcomes.Specialconcernshavebeenraised;thatlaparoscopicapproachmaycom-promisesurvivalbyfailingtoachieveaproperoncologicresectionorade-quatestaging,orbyalteringpatternsofrecurrence.Untilrecently,itwasunclearwhetherminimallyinvasivesurgeryforcolonicmalignancieswouldachieveadequateoncologicresection.Thisreviewprovidesanoverviewofrandomizedcontrolledtrialsthatreporttheshort-andlong-termout-comesafterlaparoscopiccolectomyforcancer.Theevidenceagainstanadverseeffectoflaparoscopicsurgeryforcoloncancerisstrengthened.

��

THEPASTANDFUTUREOFENDO-UROLOGYGralf Popken, PD Dr. med Department of Urology, HELIOS Klinikum Berlin-Buch, Berlin, Germany

In the preendocopic era cutting stones was a common and dangerousoperationconnectedwithahighmortality.Sincedevelopingthecystoco-pebyNitze(1879)endoscopicproceduresintheurinraytracthavebeendevelopedcontinously.

Cuttingstonesintheurinarytractwereperfomredinlessthan1%.Mostofthoseweretreatedbyextracorporoalshockwavelithotripsyandbyendo-scopicdiagnosticandtherapyinthelowerandupperurinarytract.Herebymultimodallithotripsycanbeperformed,itislessinvasiveandisconnec-tedwithalowmorbidityrate.

Justasbenignandmalignantalterationsassuperficialbladdercancerandbegineprostatehyperplasiacanbediagnosedandtreatedbyendocopicproceduresassistedbyphotodynamicdiagnostic anddifferent typesoflaser.

Thefutureofendourologieistominimizethoseinstrumentsfordiagnosticandtherapeuticproceduretomakehandlingfortheurologistandthepa-tientmorecomfortableandtominimizethetraumaaswellastopreventthosediseases.

UROLOGICALLAPAROSCOPY(FROMCUTTINGSTONESTOMINIMALINVASIVEPROCEDURES)Gralf Popken, PD Dr. med Department of Urology, HELIOS Klinikum Berlin-Buch, Berlin, Germany

Onseptember23,1901,GeorgKelling,agastroenterologistandsurgeonfromdresden,performedthefirstlaparoscopicinterventionwithanNitzecystoscopeonadoginHamburg.Althoughhispionieeringachievementshave hardly been acknowledged, modern laparoscopy has confirmedKelling´s visionsandscientificwork inalmostall aspects. In lightof theenormous develeopments of the last decades concerning laparoscopy,the ideasofGeorgKellingseemtobevisionary.Theuseof trocar,gasand light, which was described by him 100 years ago, is still valid. Hisstatementfortheuseofcelioscopy/laparoscopywithreducedtrauma,fastreconvalenscenceandreductionof treatmentcostaremoreuptodatethaneverbefore.

��

Since this time different surgical and urological endoscopic procedureshavebeendescribedintheretroperitoneum,pelvisandabdomen:1989.....Dubois.............Cholecystectomy1991.....Schuessler.......pelviclymphnodedissection1991.....Clayman..........Nephrectomy1998.....Vallancien........Prostatectomy

Nowadayswehaveseveral simpleandcomplexurological laparoscopicproceduresfromwhichsomearefirst linetherapysuchas,forexample,theadrenalectomyandthenephrectomy.

THELAPAROSCOPICNEURO-FUNCTIONALPELVICSURGERYMarc Possover*, Vito Chiantera** * Department of Obstetrics and Gynecology, St. Elisabeth-Hospital, Cologne, Germany ** Department of Gynecology and Obstetrics, University of Neaples, Italy

Wereport the feasabilityof the laparoscopicapproach toall thepelvicsomaticandautonomousnerves.Duetothemagnificationeffectandthepossibilityofabloodfreedissectioneveninthedeepnessofthepelvis,laparoscopicsurgeryintheretroperitoneumisbecomingoneofthemostuseful and important instrument for learning the pelvic retroperitonealanatomy:Usingthelaparoscopictransperitonealapproach,anexposureof thesacralplexus, thesciaticnerve, theobturatornerveandtheglu-tealnervesaswellasthepelvicsplanchnicnerveswasperformed.Basedofthisnewknowledgeofpelvicneuroanatomy,wehavedeveloppedthe„nerve-sparingLaparoscopicAssistedRadicalVaginalHysterectomy“fortherapy of patient with cervical carcinoma as well as the „laparoscopicassistedvaginalparasympathetic-nerve-sparing“resectionoftherectumwithdeepanteriorcolorectalanastomosisinextendedendometriosis.

ThisnewpossibilityofaminimalinvasivesurgicalapproachofallsomaticandautonomouspelvicnervescombinedbytheLANNtechniqueopenedthefieldofnewdisciplines,the„laparoscopicneurofunctionalpelvicsur-gery“:Wehavereportedaboutourfirstexperienceoftwoindicationsforlaparoscopicpelvicneurosurgery: - the laparoscopic neurolyse of the sciatic nerve by endometriotic infiltrationoftheforamenischiadicus - the laparoscopic neurolysis of the pudendal nerve in situation of AlcockcanalsyndromThelaparoscopicapproachtothepelvicnervesmaybecomewidespread,

��

notonlyforsparingthenervesduringradicalpelvicsurgerybutalsoonthefieldoftheFES.

LAPAROSCOPICSTAGINGOFCERVICALCANCERMarc Possover*, Vito Chiantera** * Department of Obstetrics and Gynecology, St. Elisabeth-Hospital, Cologne, Germany ** Department of Gynecology and Obstetrics, University of Neaples, Italy

While a long learning time is required tomaster the laparoscopic radi-cal lymphadenectomy and the radical vaginal hysterectomy technique,the use of laparoscopy for staging of cervical cancer should find largeresonance and is easy and quick to learn. Only the histological assess-mentoftheexpansionofatumourillnessgivesareliablereportrelatedtoprognosis.Lymphnodestatusandtumorinfiltrationinpelvictissueandtheneighbouringvisceraarethemostimportantprognosisparametersincervicalcancer.Theseparameterscanbeendoscopicallyevaluatedwithgoodreliabilitysothatthetherapycanbebetteradaptedtothetumorandthepatientismoreinvolvedinthedecision.Thehistologicalresultsoftheposteriorbladderbiopsy,pelvic/paraaortallymphnodesorsuspi-cious intraabdominal resultshelptomakethedecisionwhethersurgeryorradiochemotherapieismoreuseful.Furthermore,theextensionoftheoperativeprocedureorthesizeoftheradiationfieldcanbeindividuallyadapted.

Thelaparoscopicstagingwiththelaparoscopiclymphnodestagingshouldleadtoachangeinthestagingoflargertumors.ComputedtomographyandMagneticResonanceImagingasanindirectmethodtoprovelymphnodemetastasishavelimitedvalueofevidence.Whentheextentofor-ganinfiltrationofthebladderandtherectum/douglasislaparoscopicallyexaminedincomparisontothephotodokumentationprocedure,thereisnotenoughsensitivitywiththeMRI.Thelaparoscopicevaluationoftruetumourexpansion inaseriesof128womenwith tumours>4cm india-meter leadtoachange in thetherapeuticapproachby22,6%.Whenapreoperativechemotherapie isplanneda laparoscopic stagingcanalsoberecommendedasthetissuechangescausedbythechemotherapyorradiochemotherapymakesorientationbasedonthefrozen-sectionexami-nationonbiopsiesorlymphnodetissuedoubtfulatthefinaloperation.

Ina laparoscopichistopathologicprovenregionaltumourexpansion intotheneighbouringvisceraortotheperitoneumit ispossibletostopthe

�0

operation and change to a primary radiochemotherapie without distur-bingthebloodsupplyofthetumour.

Suchlaparoscopicstagingcanbeperformedasaday-case.Afterreceivingthehistologicalresultsthefurtherprocedurecanbeplanneddirectlywiththepatientandthroughtheomittingofthelaparotomytheradiotherapyorradiochemotherapycanbeginnquicklywithoutriskingthesideaffectsofradiationthroughextensiveadhesionsorwoundhealingdisturbances.

MANAGEMENTOFSCARRINGINENDOSCOPICSURGERYArie Rosen, MD Clinical associate professor, Otolaryngology UMDNJ, New Jersey Medical School/ Attending physician, Hackensack University Hospital, Hackensack (NJ), USA

Surgery foracquiredorcongenitalstrictures in theupperairway (UAW)oranyothertubularstructureinthebodyischallenging.Despitenewen-doscopictechniques,itcontinuestobeassociatedwithahighrecurrencerateandsubsequentstricture.Thefundamentalpredicament intreatingUAW scarring/ stenosis is how to effectively excise scar tissue withoutcreatingadditionalinjury,inevitablytriggeringfibroblastproliferation,col-lagendepositionandfibrosis-restenosis.

TopicalMitomycinC(MMC)applicationhasbeenemployedoverthelastfewyearswitheverincreasingpopularityasanadjunctforpreventionofscaringinendoscopicUAWprocedures.Thispresentationwillreviewtheuniqueanti fibroblastic effectsofMMC, current knowledgeand indica-tions for use of MMC in endoscopic UAW surgery and possible futureindicationsforitsuse.

ENDOSCOPICTREATMENTOFHYPOPHARYNGEAL-ZENKERDICVERTICULUMArie Rosen, MD Clinical associate professor, Otolaryngology UMDNJ, New Jersey Medical School/ Attending physician, Hackensack University Hospital, Hackensack (NJ), USA

Zenkerdiverticulumisanout-pouchingofhypopharyngealmucosathroughtheposteriorpharyngealwall.Itcausesregurgitationoffood,dysphagia

�1

andeventuallymalnutrition.Theconditionisoftenidentifiedintheelder-ly,medicallyfrailandnutritionallydepletedpatients.SurgeryforZenkerdiverticulumhasevolvedfromvariousopenandendoscopicproceduresthroughout most of the 20th century, to the current minimally invasiveendoscopic staplingwhichhasbeen introduced in theearly90’s. Ithasbeensincepopularized inEuropeand theUS. It isa safeandeffectiveprocedure;itrequiresashortanesthesiaandashorthospitalstay.Patientscanresumeoraldietshortlyaftertheprocedure.However,theprocedurehaslimitationsanditrequiresspecialequipment.Theauthor’sexperiencewiththeprocedureandreviewoftheliteraturewillbediscussed.

INNOVATIVECONCEPTSANDPROCEDURESINPEDIATRICENDOSCOPICALSURGERYKlaus Schaarschmidt, MD Department of Pediatric Surgery, HELIOS Klinikum Berlin-Buch, Germany

BasicpediatricdiagnosticandoperativelaparoscopyisnowusedinmanyEuropeanPediatricSurgicalcentres.Thoracoscopyandadvancedlaparo-scopicorretroperitoneoscopicproceduresarestilllimitedtoasmallnum-berofEuropeanReferenceCentresforpediatricendoscopicsurgery.

The scope of advanced pediatric and particularly neonatal laparoscopyishighlydependentontheindividualexperienceoftheteamandonthetechnicalequipmentofthehospital,highdefinition3Chipdigitalcamera,secondcamera, twoHDTVmonitors,Ultrasound scissors,water jetdis-sectorsandhighfrequencysealing,argonbeamer,5mmsetsofvariouslengths,anda2,7mminfantset,andheatableaswellashumidifiedinfla-torsandalaparoscopictraininglabforspecificphasesofdifficultoperati-onsarehighlydesirable.

Since1991ourgroupexploredandextendedthescopeofadvancedpe-diatricendoscopicsurgeryaccumulatinganexperienceof2129minimallyinvasivepediatricoperations inpediatricandadolescent surgeryof theabdomen,thoraxandretroperitoneumandintroducingmultipleinterna-tionalandEuropeannoveltechniques.

Apart from developing and applying new laparoscopic techniques likesplenectomy without staples and subtotal laparoscopic splenectomy in116childrendown toanageof1 year, sutureless intraabdominal com-pressionanastomosisin28patientswithCrohn´sdiseaseorthefirstlapa-roscopicrepairofimperforateanusin1995hybridtechniquesareincre-

��

asingly used. That is the combination of several endoscopic modalitieslikecolonoscopypluslaparoscopyforrectalperforation,cystoscopyandretroperitoneoscopyforrenaloruretericcalculi.Moreoveresophagosco-py/gastroscopypluslaparoscopyprovedexceedinglyusefulfor119child-renwithlaparoscopicThalrepairofgastroesophagealrefluxorAchalasiaparticularly for caseswithmultiplepreviousoperations inother centersandforcomplexesophagealreconstructions.Endocopicresectionsofin-creasinglylargeabdominalandtumoursarepossiblewhereeveretheyareoncologicallyjustified.

In thoracoscopy Hybrid techniques include bronchoscopy plus thoraco-scopyforournewtechniqueofthoracoscopicaortopericardiosternopexyforlife-threateningtracheomaliciaadditionbutalsobutalsoacombinati-onofendoscopicandopentechniqueforthewordwidefirstminimalac-cessrepairforpectuscarinatumappliedin46patientssofarbasedonourextensiveexperienceof436minimalaccessrepairsofpectusexcavatumincludingmultiple improvementsof theoriginalNuss technique.Finallythe technique is increasingly applied for congenital malformations likethoracoscopicrepairofcongenitaldiaphragmaticherniaorthoracoscopicanastomosisofesophagealatresiainthenewborn.

Thisexperienceamountstooneoftheearliestand largestEuropean inadvancedendoscopicPediatricSurgery.

PARALLELSBETWEENAIRFLIGHTANDSURGERYCarsten Schmidt Lufthansa, Austria

Onfirstsight,theworkofpilotsandsurgeonsseemstobeverydifferent.Butitmaywellbecompared:bothgroupsareinfluencedbyasimilarva-rietyof inputfactors;anumberofprofessionalsmustcometogethertoperformmultipleandcomplextasksinanoisyandclutteredenvironment.Activitiesmustbecoordinatedandaddingtothecomplexityoftheenvi-ronment,theconditionofthepatientsisashighlyvariableasthecockpitcrew`sworkload.Medicalcatastrophesalsocomeunderinvestigation,butnotaspubliclyorintensivelyasairdisasters.Forexample70%ofincidentsinanesthesialikeinaviationareduetothehumanerror.

Around1988,firstmajorairlinesbegantrainingtheircrewsin“CrewRes-sourceManagement” (CRM) to reduce thishumanerror and to reduce

��

risks in theirdailyoperation.ThisCRMtraininghasbecome the funda-mentalbaseforasafeairlineoperation.Thetrainingincludeseverybodyinvolvedintheprocessofflight.

Lookingatthehumanerror,wecanevaluatedifferenttypesoferrorsbeingmadebydifferentpeopleinthehierarchy.Thecaptainorseniorhaspro-blemswithtakingtherightdecisionwhilethecopilotortheassistanthashisproblemswithbeingassertive.Thecombinationofbotherror-typesisfatal.Thegoodnews:itcanverywellbetrained.

Wewillnowonlylookatthecaptainsorseniorsproblemoftakingagooddecision.Majorairlinesuseasocalled“FORDEC-model”.FORDECstandsforF =FACTS:collectingfactsO=OPTIONS:lookingfordifferentoptionsR =RISKS&BENEFITS:evaluatingtherisksandbenefitsofeach optionmentionedaboveD=DECISION:takingthedecisionbychoosingthebestoptionE =EXECUTION:executethedecisionC = Checkwhetherthedecisionisstillcorrectinthechanging environment

Astructured,sometimestimeconsumingdecisionmakingprocesswithinateamcontradictspeople´sdesiretoactandtoleadinasuperiorway.Andmostofall,risksareoftenjudgedwronglybyindividuals.Talkingabouttheproblemofindividualriskevaluation,wehavetotalkabouttheprobabilityofafatalaccident.Lufthansa´stargetvalueofcourseisthe“zeroaccidentrate”.Approachingthisvalue,theriskofafatalcrashmustbefarbelow10-7incidentsperflighttohavelessthenoneaccidentevery15years.Theproblemmentionedaboveis:nobodyhasafeelingfora10-7risk.

TakingtherightdecisionmeansconsideringaFORDECincludingthewho-leteam.Therequiredsafetymargindoesnotcorrespondtoourdailyandindividuallyfeltrisks.Beingoldageandhavingalotofexperience,kno-wingyoutooktherightdecisionahundredtimesonlymeansasafetylevelof10-2.

Astructureddecisionmakingprocessisonewaytoasaferoperationinanyhighriskenvironment.ThisshouldbetrainedonregularbasesaspartofaCRMtraining.Withthistraining,wewillreachsafetylevelswhicharefarbelowourownsubjectivelyfeltrisk-threshold.

��

MINIMALINVASIVETREATMENTOFTHORACOLUMBALBURSTFRACTURESSchmidt J, Teßmann UJ HELIOS Klinikum Berlin-Buch, Berlin, Germany

INTRODUCTION:Fromthebiomechanicalviewspinefractureshastobetreateddorso-ven-trallyiftheyareaccompaniedwithatearofthevertebraldisc.TheAO-classificationrelatestothosecollateralinjuries.Inthesecases,wehavetoresectthevertebraldiscandankylosethissegment.Inthelast10years,thisprocedurehasbeenperformedbyleftsidedthoracotomy.Inthelast2years,vidoescopicassistedprocedureshavebeenestablishedwithanenormousadvantageforthepatients.

METHODS:Since 2003, we treated 96 burst fractures of the thoracolumbal regionusingvideoscopicassistedoperation. In2cases,wehadtochangedu-ringtheoperationtothoracotomy.In82cases,weworkedoutamono-segmentalspondylodesis,14casesneededabisegmentalstabilisation.Inthe lastcases,wesupportedourstabilisationwithaventralankelstableosteosynthesis.Asreplacementforthevertebraldisc,weusedinallmo-nosegmental treatments cortico-cancellousbonegrafts from thepelvis.Oneofthegreatestproblemsinthisoperationintheindirectviewofthecameraistheplacementofthegraft.Sowedevelopedatargetingtool(vertebrometer).

RESULTS:Inall cases,weachievedaproperpositionof thegraft.Therewerenosecondary neurological deficits. Thoracal drains were removed after 24hours,afterthisallpatientsweremobilized.Thepatientscouldleaveourhospital10daysaftertreatmentinaverage.Thereturntoworkwasinave-rage4monthaftertreatmentindependentlyoftheprofession.

SUMMARY:Thevideoscopically assisted treatmentof thoracolumbalburst fractureshas an enormous advantage in spine surgery. The recovery of patientstakesshortertime,theoperationprocedureissafer.Thevertebrometeristhenextstepinthedevelopmentofthismethod.

��

THECOMBINEDLAPAROSCOPICANDVAGINALAPPROACHINGYNAECOLOGICALMALIGNANCIESSchneider A, Köhler C Clinic of Gynecology, Charité Campus Benjamin Franklin, Berlin, Germany

Laparoscopic-assistedradicalvaginalhysterectomyandradicaltrachylec-tomy are well standardized surgical procedures with low complicationrates.Bybloodlessdisectionandmagnificationviathelaparoscopener-ve-preservingtechniquescanbedonewhichreducesignificantlymorbi-dity of bladder and bowel. Patients with cervical cancer of less than 4cmØ,histopathologicnegativelymphnodes,andabsenceofhemovas-cular tumor-involvementare idealcandidates forsurgical treatmentalo-neby laparoscopic-assistedradicalvaginalhysterectomycombinedwithtransperitoneal lymphadenectomy.WhenradicalhysterectomytypeIII isindicated this can be done in a nerve-sparing concept. Radical vaginaltrachelectomyincombinationwithlaparoscopiclymphadenectomyallowspreservationoffertilitywithoncologicsafetyandgoodresultsforpreg-nancyandchild.

Patients with endometrial cancer profit from a combined laparoscopicvaginalapproach,especiallyinthepresenceofoneofthefollowingfac-tors:co-morbiditybyothermedicalconditions,weightofmorethan80kg,Quetelet-Index>30,orageofmorethan65years.Theearlyandlatepostoperativephaseofthesepatientsissignificantlyimproved.

Thus,thecombinedlaparoscopicvaginalapproachshouldbemasteredbyeverygynaecologicaloncologistwhowantstoofferthecompletespec-trumoftreatmentoptionstohispatients.

THETRANSPERITONEALLYMPHADENECTOMYSchneider A, Köhler C Clinic of Gynecology, Charité Campus Benjamin Franklin, Berlin, Germany

Laparoscopic lymphadenectomy is a prerequisite for staging and treat-mentofpatientswithgynaecologiccancers.Thelearningcurveforpelviclymphadenectomy isshort,asopposedtoparaaortic lymphadenectomywhereitislong.Thenumberofremovedpelviclymphnodesandthedura-tionoftheprocedureareindependentoftheBody-Mass-Index.Followingstandardizationofthetechnique,nosevereintraoperativecomplicationsareencountered. Inpatientswithcervicalcancer<2cmØthesentinel

��

lymph node concept is associated with high sensitivity and a low rateof false-negatives.Detectionofcirculatingtumorcells insentinel lymphnodesusingHPV-messengerRNAasamarkeriscurrentlyevaluatedinitspotentialasaprognosticmarker.Transperitoneallymphadenectomyisanessentialprerequisiteforstagingofpatientswithinvasivecervicalcancerinordertoselectanindividualizedandoptimaltherapeuticstrategy.Patientswith negative lymph nodes are candidates for primary chemoradiation.Debulkingoftumor-involvedlymphnodesinthepelvicand/orparaaorticareaisassociatedwithimprovedsurvival.Laparoscopicevaluationofthelymphnodestatusleadstoupstaginginupto80%ofthepatientswhicharelymphnodenegativebyconventionalimagingtechniques.Thus,lapa-roscopiclymphnodestagingshouldbeintegratedintotheroutinestagingofpatientswithcervicalcancerandreplacecurrentFIGO-staging.

Inpatientswithendometrialandearlyovariancancerpelvicandinfrarenalparaaorticlymphadenectomyisfeasible.Especiallyold,obese,andmulti-morbidpatientswithendometrialcancerprofitfromlaparoscopiclymph-adenectomywithrespecttoearlyandlatepostoperativecomplications.

Laparoscopiclymphadenectomyisanessentialpartofstagingandtreat-mentofpatientswithcervical,endometrialandearlyovariancancerandhastobeintegratedinthearmamentariumofgynecologiconcologists.

FOCUSEDULTRASOUNDTHERAPY:UTERINEFIBROIDSANDBEYONDElizabeth A. Stewart, MD, Clare M.C. Tempany, MD Departments of Obstetrics, Gynecology and Reproductive Biology and Radiology, Brigham and Women‘s Hospital and Harvard Medical School, Boston, USA

Clinical treatment of uterine fibroids using high-intensity focused ultra-sound(HIFU)orfocusedultrasoundsurgery(FUS)isthefruitionofmanydecadesofresearch.FUSprovidesthermoablativetherapywithoutplace-mentofaprobeintothetarget.MRIguidanceprovidesclearimagingofbothtargetandnon-targettissuesandprovidesreal-timethermalfeed-back.Thecombinationoftheseassetsmaximizessafetyandefficacyandallowsforsurgicalinnovationwhileprotectinghumansubjects.

Predictorsofclinicalsuccessarebeginningtobeunderstoodwiththisthe-rapy.Themechanismofcoagulativenecrosisappearstoavoidthepost-

��

embolizationsyndromeseenfollowingtheischemicnecrosisofUAEandtoallowforoutpatienttherapywitharapidreturntowork.

Foruterinefibroids,optimizationoftreatmentprotocolsandinvestigati-onofthesafetyofFUSforwomenwhodesirefertilityremainkeyissues.Additionalapplicationsforthistechniqueincludeanumberofbenignandmalignantdiseases.Ultrasound-guidedHIFUdevicesarealsobeingstu-diedandmayprovideadditionalapproachestogynecologicdiseases.Thenon-invasivenatureofFUSmayleadtoearly interventionorpreventionstrategiesinthefuture.

GENETICSANDFIBROIDS:THEFUTUREISNOWElizabeth A. Stewart, MD, Cynthis C. Morton, Ph.D Departments of Obstetrics, Gynecology and Reproductive Biology and Radiology, Brigham and Women‘s Hospital and Harvard Medical School, Boston, USA

Thediversityofbothclinicalphenotypeandkaryotypicabnormalities inuterine fibroids (leiomyomas) suggests there may be many underlyinggenes influencingwhat is currentlyviewedasonediseaseprocess.Thegeneticsofmanycomplexdiseases,includinghypertension,diabetesandasthma,arereceivingintenseinvestigationandthisshouldbeourmodelforaresearchagenda.

Foruterinefibroids,knowledgeoftheparticulargenesinfluencingdiseaseisnolongeraconcernforthefuture.Newinformationonthegeneticsofuterinefibroidsisrelevanttocliniciansandpatientsbecausesomegeneticsyndromesinvolvingleiomyomascarryanincreasedriskofmalignantdi-seasebothforthewomanwithfibroidsandherfamily.Wearealsobeginningtounderstandsomegenotype/phenotyperelation-shipsfortheseprevalenttumors.Itisalsobecomingclearthatthereisadi-stinctgeneticriskforwomenofcolor,whichlikelyexplainstheirincreasedprevalence,andseverityofdisease.

Agenome-widescansuchastheFindingGenesforFibroidStudy(www.fibroids.net)willbecrucialinuncoveringnovelgenesthatpredisposetothisdiseaseor causegrowthacceleration.Knowledgeofgene/environ-mentinteractionswillallownovelpreventionstrategiesforhigh-riskwo-meninthefuture.

��

THEFASTTRACKCONCEPTINCOLONSURGERYAlbert Tuchmann, MD Hospital Floridsdorf, Vienna, Austria

DEFINITION:Fasttracksurgeryisaconceptofacceleratedconvalescence.Thefunda-mentalsofthisnewconceptarepatients’exactinformationandcooperati-on,perioperativeanalgesiawithanepiduralcatheter,earlypostoperativeoralfeedingandearlymobilisation.

PATIENTS:142patients (Feb.2004-Oct.2005)were treatedwith the fast track con-cept.Wecomparedthesepatientsto167patientswithconventionalcare(operatedbetweenJan.2002andDec.2003).

DIAGNOSES:68Carcinomainthefasttrackgroup,99withconventionalcare.Laparoscopic operations: 126 in the fast track group, 72 conventionalcare.Hospitalstay:6days(fasttrack)vs.12days(conventionalcare).Surgicalcomplicationswereequalinbothgroups,butnon-surgicalcom-plications(lung,heart,intestinalparalysis)werereducedsignificantly:4%fasttrackvs.30%conventionalcare.Mortality2%vs.7%.Thereadmissionratewas7%inthefasttrackgroup.

SUMMARY:The fast track concept was feasible in unselected colorectal patients.Generalcomplications (lung,heart, intestinalparalysis)werereducedsi-gnificantly.Thehospitalstaywashalfcomparedtotheconventionalcarepatients.

LAPAROSCOPICTREATMENTOFCOLORECTALCANCERAlbert Tuchmann, MD Hospital Floridsdorf, Vienna, Austria

INTRODUCTION:There isanongoingcontroversyabout laparoscopicoperationsofcolo-rectalcancerduetotechnicaldifficulties,suspectedlocalrecurrenceandportsidemetastases.Nevertheless,laparoscopiccolorectalcancersurgeryhasbeenperformedsuccessfullyinspecializedcenters.

��

PATIENTS:Laparoscopiccolonsurgeryforbenignconditions(diverticulitis,adenoma)hasbeenperformedatFloridsdorfhospitalsince1999.Afterthesefirstex-periences,thelaparoscopictechniquewasappliedtocolorectalcancerca-ses:93patientswereoperated(53coloncarcinoma,40rectalcarcinoma).

RESULTS:7/93=6% anastomotic insufficiency. Wound complications 11/93=12%.Peritonitiscausedbyintestinalperforation1,pulmonaryembolism1,myo-cardialinfarction1.Mortality2/93=2%.Followup:Averagefollow-upwas12months(1-49m).Therewasnolocalrecurrenceandnoportsidemetastasis.Livermetastasesoccurredintwopatients,sixoutofsevenpatientsdiedbecauseoftumorprogression.

SUMMARY:Laparoscopic colorectal cancer surgery according to oncologic rules ispossible(withouttechnicaldifficulties).However,thelongtermresultswillhavetobeevaluatedcarefully.

ANESTHESIAFORTHE„NEW“PATIENTHAVINGLAPAROSCOPICSURGERY:5YEARSFROMNOWKlaus F. Wagner, MD Clinic of Anesthesiology, University Luebeck, UKSH-CL, Germany

INTRODUCTION:A focus of perioperative medicine in the near furture will be the over-weightandtheold-agepatients:bariatricsandtheoctogenarians.Patientcare for them is challenging forboth the surgeonsand theanesthesio-logists.Thispresentationwillfocusonthepeculiaritiesofanesthesiaforbariatricandold-agepatientsaswellastheimplicationsforteamperiope-rativemanagement.

DISCUSSION:DifficultIntubationofbariatricpatientscanbeexpectediftheskin-cricoiddistanceismorethan28mm,thoughbeingoverweightisnotariskfactorpredictiveofadifficultintubation.Androidbodymassdistributionisariskfactorforcoronaryheartdiseaseandandroidstatureinabariatricspatientdeservesmore thoroughpreoperativecardiovasuclarassessment.Baria-tricswithgynecoidbodymassdistributionontheotherhanddonotseemto have an increased incidence of coronary arteriosclerosis. In bariatricpatiants,apartfromcardiovascularmorbidity,pulmonarypathophysiology

�0

andpharmacokineticsshow importantdifferencescomparedtonormalpatients.Theseissueswillbeaddressedandtheirimplicationsonthepe-rioperativemanagementwillbediscussed.Demographyhasintroducedandcontinuestointroducepatientstosur-gicaltherapywhohavebeentermedoctogenarians(80+years),nonage-nariens(90+years)andevencentenarians(100+years).Thosewillbethepatientswewillcareforinthefuture.Asstatedforbariatricpatients,oldagepatientshaveannumberofpathophysiologicalcharacteristics.Theymostofallalludetothecardiovasuclarsystemandthecerebralfunction.Thuspostoperativecognitivedysfunction isofparticularconcern in thispatientgroup.

CONCLUSION:Whiletheanaestheticofchoicefortheoctogenarianhasyettobedeter-mined,thetreatmentteamhastomakeeveryefforttoapproachthisveryimportantpatientgrouptotheirhospital.Advancingcareforthebariatricandtheelderlypatientwillbeaworthwhileandrewardingchallengeofthefuture.

ANESTHESIAANDTHEFUTUREOPERATIVEENVIRONMENTFORLAPAROSCOPICSURGERYKlaus F. Wagner, MD Clinic of Anesthesiology, University Luebeck, UKSH-CL, Germany

INTRODUCTION:Endoscopic,minimallyinvasivesurgeryisestablishedandthrivinginGe-neralSurgery,Gynaecology,Urology,andOtolaryngology.Anaesthesiolo-gyhasadaptedtothechallengesofpositioning,darknessandspeed.Yet,theeverydayoperativeenvironmentencounteredinmostORsisfarfromoptimizingandsimplifyingsurgicalprocedures.Todeliverer thehigheststandardof carewithbestoutcomeandpatient satisfaction; the futureoperativeenvironmenthastobeintegrated,simpleandergonomic.ThislecturewillpresentsomeingredientsofORintegrationandORergono-micsthatallowfora„tasty“operativeenvironment.

DISCUSSION:For many procedures endoscopic surgery outperforms open surgery.Butseveraldisadvantagesareinherenttotheendoscopicapproach.Theequipmentiscomplicatedandconsistsofmanystandalonedevices,er-gonomicsisiflowpriority,ahighstandardoftrainingismandatory,and

�1

patientthroughisnotalwayshigh.Toovercometheseobstaclesthepro-jectFUSIONwasstarted.FUSIONaimstoanalyseshortcomingsofthecurrentORsettingforminimallyinvasivesurgeryandtodesignanopera-tivecockpitcorroboratingdiagnostics,superiorendoscopicinstruments,andanintegratedanaesthesiaworkingenvironment.Whilethedesignofmoreergonomicinstrumentsisafruitfulendeavourcollaboratingwithre-spectivecompanies,thequestionofwhichandhowmanydiagnostictech-niqueshavetobeavailableintheORremainsunanswered.TheimpactofadecisiontointegrateanMRIintotheORhasmarkedimplicationsforthesurgicalequipmentaswellastheanaestheticmachineryandisextremelycostly.Thus,currentlyMRIintheORisnotfavoured.Still,the3DimagesgeneratedbyMRIaregoldstandard.Analternativeapproachistheinte-grationofthedataofvariousdiagnosticmethods(X-ray,ultrasound,PET,etc.)intoa3DsynopticimagevisualizedintheOR.Butthegenerationofthissynopticimageisahugechallengetoimageprocessingandsysteminterfaces.Tofurthercomplicatethematter,thepatient’sdigitalmedicalrecordsshouldtobeavailable in the integrated,simpleandergonomicORofthefuture.

CONCLUSION:„The spirit is willing but the flesh is weak“. The future operative envi-ronmentfor laparoscopicsurgery isstartingtoemergebut lotsofworkremainstobedoneuntilergonomicsimplicityandintegrationareachie-ved.

CRYOMYOLYSISANDLAPAROSCOPYErrico Zupi, MD University of Rome ‚Tor Vergata‘, Rome, Italy

OBJECTIVE:Toevaluate the long-termeffectivenessof laparoscopiccryomyolysisasaminimallyinvasivetechniqueforthetreatmentofsymptomaticuterinemyomasinmenstruatingwomen.

DESIGN:Openonearmpilotstudy

SETTING:Universityaffiliatedpublichospital

��

PATIENTS:20patientswithsymptomaticuterinefibroidsweretreatedwithdirectedcryomyolysis.Allhadcomplaintsofeitherabnormalbleedingand/orpel-vicpain/pressureand/orurinaryfrequency.Myomadiametersvariedfrom4to10cm..

INTERVENTION:Oneyearfollow-upafterlaparoscopicdirectedcryomyolysis,

MEASUREMENTANDMAINRESULTS:LaparoscopiccryomyolysiswasperformedusingtheHerOption™Cryo-ablationUnit.(AmericanMedicalSystems,Minneapolis,Minnesota,USA)Patientswereevaluatedatone,three,6,9,and12monthspostoperative.PowerColorDopplerwasperformedpreandpostoperativetodemon-strate theeffectivenessof the technique in reducingoreliminating theprimarybloodsupplyofaswelldocumentingregressionofthemyomas.

Allpatientsreportedahighrateofsatisfactionwiththetreatmentinclu-dingabsenceofsymptomsafter12monthsfromthesurgery,withnoblee-ding,nomyomasrelatedsymptoms,comparabletopatientswhounder-wenthysterectomy.

Meanshrinkageoffibroidsvolumeincreaseduntil9months(59.5%±13.2%)reachingasteadymeanvolumereductionaround60%(61.9%±11.9%)at12monthsfromsurgery.

CONCLUSIONS:DirectedLaparoscopiccryomyolysisappearstobeaneffectiveandsafetechniqueinprovidingrapidsymptomreliefandatleast12monthseffec-tivenessinthetreatmentofsymptomaticuterineleiomyomas.

LAPAROSCOPICAPPROACHTODERMOIDCYSTS:COMBINEDSURGICALTECHNIQUEANDULTRASONOGRAPHICEVALUATIONOFRESIDUALFUNCTIONINGOVARIANTISSUEErrico Zupi, MD University of Rome ‚Tor Vergata‘, Rome, Italy

Dermoidcystsarisefromgermcellafterthefirstmeioticdivisionandac-count for5%to25%ofallovariancysts,makingthemoneofthemostcommonovarianneoplasminwomeninthereproductiveage.Thesebe-

��

nigntumorsaremostfrequentlydiagnosedinyoungwomenandmayin-terferewithfertilityorcausepain,adnexaltorsionorrupture.Advancesinendoscopicsurgerypermitlaparoscopictretmentofovariancyststhatpreviouslyrequiredlaparotomyandatthepresentlaparoscopicmanage-mentofovariandermoidcystsisthetechniqueofchoice.

OBJECTIVE:Estimatehowand if laparoscopic removalofovariandermoidcysts isatissue-sparingprocedure

DESIGN:Prospectivestudy

SETTING:University-associatedhospital

INTERVENTION:Laparoscopicremovalofovariandermoidcystsbyacombinationofhydro-dissectionandbluntdissection,andtransvaginalsonographicevaluationofresidualovariantissue.

MEASUREMENTSANDMAINRESULTS:Within1weekbeforesurgeryallrecruitedpatientsunderwenttoTVSeva-luation of ovarian volume, size, and morphology of dermoid cysts andmeasurement of surrounding ovarian cortex. Mean cyst diameter was5,5+/- 2,2 cm (range 2,1-15,0): Within 6 to 12 months after laparosco-picexcision,TVSmeasurementsofresidualovariantissuewereobtained.OvarianresidualcortexsurroundingthecystwasnotvisibileatTVSin24ovaries,whereasin56ovariesresidualtissuevolumewasgreaterthan3cm3afterlaparoscopicexcision.

CONCLUSION:Weproposelaparoscopicremovalofdermoidcystsbycombininghydro-dissectionandbluntdissectionwithmaximal tissue sparing,evenwhenthecystsseemtofilltheovaryandnosurroundingovariancortexcanbeseenonultrasound.

��

HYSTEROSCOPICENDOMETRIALRESECTIONVERSUSLAPARO-SCOPICSUPRACERVICALHYSTERECTOMYFORMENORRHAGIA:APROSPECTIVERANDOMIZEDTRIALErrico Zupi, MD University of Rome ‚Tor Vergata‘, Rome, Italy

OBJECTIVE:Thisstudywasundertakentocomparetherelativeefficiencyandsafetyofhysteroscopicendometrialresectionandlaparoscopicsupracervicalhyste-rectomyinthetreatmentofabnormaluterinebleeding.

STUDYDESIGN:Onehundredeighty-onepatientssufferingfrommenometrorrhagiaandnotrespondingtomedicaltreatmentagreedtoberandomizedtoeitherlaparoscopicsupracervicalhysterectomyorhysteroscopicendometrialab-lation.Theyweremonitoredfor2yearstoevaluateperioperativeandpost-operativeoutcomes,resolutionofsymptoms,andpatientsatisfaction.

RESULTS:Durationofhospitalization,periodofconvalescence,perioperativecom-plications, and resumption of normal activity were similar between thetwogroups.Operativetimewassignificantlyshorterinthehysteroscopicgroup,butpatientsatisfactionwassignificantlyhigherinthelaparoscopicgroup.

CONCLUSION:Forthetreatmentofmenorrhagia,hysterectomyhasthedistinctadvantageofbeingcurativebutthedisadvantageofbeingmoreinvasivethanthehy-steroscopicapproach.However,laparoscopicsupracervicalhysterectomypreservesthecurativeeffectofhysterectomywithoutitsincreasedsurgicalinvasiveness,assuggestedbythecurrentstudy.

��

Usefulinformation

Organisationofthecongress:ClémenceDelmasSabineWolfTheNewEuropeanSurgicalAcademy(NESA)KarowerStrasse11/214D-13125Berlin,GermanyPhone:+49(0)309401-2993Fax:+49(0)309401-2430www.nesacademy.org

CongressOffice:INTERPLANCongress,Meeting&EventManagementAGMrs.JohannaKrauseAlbert-Rosshaupter-Strasse65D-81369Munich,GermanyPhone:+49(0)8954823411Fax:+49(0)8954823443Email:nesa06@interplan.dewww.interplan.de

HiltonHotelBerlinMohrenstrasse30D-10117Berlin,GermanyPhone:+49(0)302023-0www.hilton.com

Layout:JürgenDachnerWiltbergstrasse50D-13125Berlin,Germany

��

��

��

The New European Surgical Academy (NESA)Karower Strasse 11/�1�

D-1�1�� Berlin, Germany Phone: +�� (0)�0 ��01-����

Fax: +�� (0)�0 ��01-���0 www.nesacademy.org