Lysis Of Adhesions Research Articles

RANTES Concentration at the Time of Surgery Is Associated With Postoperative Stiffness in Patients Undergoing ACL Reconstruction

Background: Patients undergoing anterior cruciate ligament (ACL) reconstruction have been shown to be at risk for postoperative arthrofibrosis. Diagnostic biomarkers associated with the development of postoperative stiffness are unknown. Hypothesis: Biomarkers found in the synovial fluid at the time of surgery are associated with the development of postoperative arthrofibrosis in a cohort of patients undergoing ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing ACL reconstruction were prospectively enrolled. Synovial fluid was collected before surgical incision. A cohort of patients with postoperative stiffness requiring manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) was retrospectively identified. Matching of cases to controls was performed using a 1:2 pair matching algorithm. Risk factor–adjusted single-biomarker and multivariable models were used to assess the association of synovial fluid biomarkers with postoperative stiffness requiring MUA/LOA. Stepwise logistic regression controlling for clinical risk factors was used to identify biomarkers that are possible predictors of postoperative stiffness. Results: A total of 11 cases (3 male, 8 female) were identified and matched with 21 controls (6 male, 15 female) with no significant differences in age, sex, smoking history, or days from injury to surgery. Concentrations of the biomarker regulated upon activation, normal T-cell expressed and presumably secreted (RANTES) were significantly higher in patients requiring MUA/LOA versus controls (694.20 pg/mL [interquartile range, 214.75-3428.79] vs 113.04 pg/mL [interquartile range, 32.81-517.91], respectively; P = .034). On single-biomarker models, RANTES (odds ratio, 2.28; 95% CI, 1.29-5.37; P = .019) and basic fibroblast growth factor (bFGF) (odds ratio, 1.91; 95% CI, 1.07-3.99; P = .047) were associated with increased risk of postoperative stiffness requiring MUA/LOA after ACL reconstruction. Stepwise logistic regression identified 3 biomarkers that are possible predictors of postoperative stiffness, which were included in the final model: Interleukin 1 receptor antagonist (IL-1RA) (P = .198), bFGF (P = .157), and RANTES (P = .046). Conclusion: Higher concentrations of synovial fluid biomarkers bFGF and RANTES were associated with increased risk for stiffness requiring intervention after ACL reconstruction. Interleukin 6 (IL-6), vascular endothelial growth factor A (VEGF-A), tissue inhibitor of metalloproteinases 1 (TIMP-1), interleukin 1 receptor antagonist (IL-1RA), matrix metalloproteinase 3 (MMP-3), monocyte chemotactic protein 1 (MCP-1), and macrophage inflammatory protein 1B (MIP-1B) were not associated with the development of postoperative arthrofibrosis.

Anticoagulant Usage After Anterior Cruciate Ligament Reconstruction Is Associated With Increased Rate of Manipulation Under Anesthesia.

Arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) is a notable but uncommon complication of ACLR. To improve range of motion after ACLR, aggressive physical therapy, arthroscopic/open lysis of adhesions, and revision surgery are currently used. Manipulation under anesthesia (MUA) is also a reasonable choice for an appropriate subset of patients with inadequate range of motion after ACLR. Recently, the correlation between anticoagulant usage and arthrofibrosis after total knee arthroplasty has become an area of interest. The purpose of this study was to determine whether anticoagulant use has a similar effect on the incidence of MUA after ACLR. The Mariner data set of the PearlDiver database was used to conduct this retrospective cohort study. Patients with an isolated ACLR were identified by using Current Procedural Terminology codes. Patients were then stratified by MUA within 2 years of ACLR, and the use of postoperative anticoagulation was identified. In addition, patient demographics, medical comorbidities, and timing of ACLR were recorded. Univariate and multivariable analyses were used to model independent risk factors for MUA. We identified 216,147 patients who underwent isolated ACLR. Of these patients, 3,494 (1.62%) underwent MUA within 2 years. Patients who were on anticoagulants after ACLR were more likely to require an MUA (odds ratio [OR]: 2.181; P < 0.001), specifically low-molecular-weight heparin (OR: 2.651; P < 0.001), warfarin (OR: 1.529; P < 0.001), and direct factor Xa inhibitors (OR: 1.957; P < 0.001). In conclusion, arthrofibrosis after ACLR is associated with the use of preoperative or postoperative thromboprophylaxis. Healthcare providers should be aware of increased stiffness among these patients and treat them aggressively.

Elastotic Mass-Forming Lesion of the Omentum; A New Pathological Entity

Abstract Introduction/Objective Elastotic lesions are rare benign mass-forming entity. Although, few reports of mucosal and submucosal elastotic lesions have been previously described, localization of these lesions in the omentum is not previously described in the literature. Methods/Case Report We report a case of 60-year-old man with medical history of obesity, hypertension, diabetes mellitus, and a remote abdominal surgery in 1980s who presented to the emergency room complaining of abrupt severe constant epigastric pain that started few hours before. The pain was not relieved by antiacid or analgesic medications. CT of the abdomen showed multiple distended fluid-filled loops of small bowel in mid abdomen with infiltrative changes of mesentery. A diagnosis of small bowel obstruction was made, and patient proceed to have an exploratory laparotomy. During the procedure, extensive adhesions between small bowel and omentum and small bowel obstruction due to a phytobezoar were noted for which he underwent lysis of adhesion, excision of thickened omentum, and enterotomy for removal of significant food bezoar. Grossly, the omentum has multiple chalky tan-gray masses ranging between 1.2 and 1.0 cm in greatest dimension surrounded by indurated fatty tissue. Microscopically, multiple hypocellular foci are seen that are composed almost entirely of truncated elastic fibers, with sparse delicate bands of collagen and scattered prominent thick-walled vessels. Elastic stain highlights these elastic fibers while trichrome stains the elastic fibers pale gray in contrast to the bright blue color of the collagen fibers. Mucicarmine, and Congo red are negative. Patient tolerated the procedure well however, postoperatively he had local wound infection leading to prolonged skin dehiscence. Results (if a Case Study enter NA) NA. Conclusion Elastotic mass-forming lesions in the omentum is a new entity that has not been described before in this location that can clinically manifest with signs and symptoms of bowel obstruction. We suggested the name of elastomatosis omentum.

Recurrent Small Bowel Obstruction and Perforation as a Complication of EFEMP1-Associated Systemic Venous Amyloidosis

Abstract Introduction/Objective Amyloidogenic protein EGF-containing fibulin-like extracellular matrix protein 1 (EFEMP1) is a newly described age-related systemic venous amyloidosis. EFEMP1 venous deposition has recently been reported in postmortem gastrointestinal specimens in which the deceased presented with gastrointestinal bleeding. Methods/Case Report We report a case of a 53-year-old female with long-standing seronegative spondylitis, and multiple recurrent small bowel obstructions and perforations status post surgical interventions who presented with 3 days of generalized abdominal pain, 10/10 in severity with nausea, emesis and absence of bowel movement. Abdominal CT scan confirmed closed loop obstruction in the left hemi-abdomen. An emergent partial duodenectomy was performed with extensive lysis of adhesion which revealed a perforated jejunal diverticulum with abscess formation. Microscopic examination demonstrated the presence of eosinophilic, amorphous, acellular material in the venules of the duodenum wall. Congo red stain demonstrating the presence of amyloid deposits and the specimen was sent for amyloid typing. Liquid chromatography tandem mass spectrometry demonstrated a peptide profile consisting of serum amyloid P, apolipoprotein A4, apolipoprotein E, and abundant peptides associated with EFEMP1/FBLN3 consistent with a recently described age-related venous amyloidosis derived from EFEMP1 protein. Results (if a Case Study enter NA) N/A. Conclusion EFEMP1-associated systemic venous amyloidosis has a predilection for females with a median age of 75 years and almost exclusively occurs in the gastrointestinal tract. We report this case for its novelty, unique clinical presentation and to emphasize awareness of this entity as we learn more about its etiology, presentation, management, and prognostication.

Abstract 15668: Concurrent ST Elevation Myocardial Infarction and Gastric Perforation: A Management Dilemma

Case Presentation: A 62-year-old male with RBBB, hypertension, diabetes, and former tobacco use presented with nausea, vomiting, abdominal and chest pain which responded to Pepto-Bismol. Examination revealed tachycardia, hypertension, a rigid, tender abdomen with guarding and rebound. His ECG showed anterolateral STEMI with dynamic changes. Chest and abdomen CT revealed a perforated ulcer with free air and also noted a hypodense region of the LV in the vascular distribution of the LAD suggestive of an acute infarct. Echo revealed LAD territory wall motion abnormalities with an estimated LVEF of 35%. It was decided to proceed with coronary angiography first based a multidisciplinary team discussion between the patient, surgical, and cardiology team. This showed a totally occluded proximal LAD, felt to be the culprit lesion, 90% proximal stenosis of LCx, and diffuse disease of RCA (figure). Right heart catheterization showed mixed shock. Plain old balloon angioplasty of LAD was done, IABP placed, and pressors started. He then had an exploratory laparotomy with lysis of adhesions and Graham patch repair of perforated gastric ulcer. He ultimately had a DES to his LAD 15 days after tolerating DAPT. Repeat Echo done after 2 months of GDMT revealed a recovered LVEF of 55%. Discussion: STEMI and perforated viscus are two clinical emergencies with high mortality. Few case reports of simultaneous occurrence are documented in the literature with no guideline-directed management given the rarity of its presentation. In our patient, we preceded with coronary angiogram to attain moderate hemodynamic stability with POBA aiding in revascularization and IABP providing mechanical support. Furthermore, early revascularization in STEMI is known to have mortality benefits. Our approach led to a favorable outcome with resultant recovery in cardiac performance and can be considered as a strategy to tackle similar presentations with expert deliberation.

Major adverse cardiovascular events and all-cause mortality after emergency general surgery among kidney failure patients.

Emergency general surgery (EGS) is associated with increased mortality, with kidney failure a contributing risk, but comparative outcomes between patients with kidney failure and the general population are lacking. In this retrospective population-cohort study, data were analysed for all EGS procedures performed in England between 1 April 2004 and 31 March 2019. EGS was defined as partial colectomy, small bowel resection, cholecystectomy, appendicectomy, lysis of peritoneal adhesions, surgery for peptic ulcer, or laparotomy. The main outcome measure was major adverse cardiovascular events (MACEs) and all-cause mortality after surgery. From 691 064 procedures, 0.16 per cent (n = 1097) and 0.23 per cent (n = 1567) were performed on kidney transplant and dialysis recipients respectively. Laparotomy was the most frequent EGS procedure for kidney transplant (46 per cent of procedures, n = 507) and dialysis (45 per cent of procedures, n = 704) recipients, with the highest 30-day and 1-year mortality. In logistic regression analysis, both kidney failure cohorts had higher risk for experiencing MACEs in the postoperative interval after emergency laparotomy; within 3 months (dialysis; OR 2.44 (95 per cent c.i. 2.08 to 2.87), P &lt; 0.001 and transplant; OR 2.05 (95 per cent c.i. 1.57 to 2.68), P &lt; 0.001) and within 1 year (dialysis; OR 2.39 (95 per cent c.i. 2.06 to 2.77), P &lt; 0.001 and transplant; OR 2.21 (95 per cent c.i. 1.76 to 2.77), P &lt; 0.001); however, in a propensity-score-matched cohort, increased risk for MACEs was observed among dialysis patients after emergency laparotomy (HR 2.10 (95 per cent c.i. 1.82 to 2.43), P &lt; 0.001) but not kidney transplant recipients (HR 1.17 (95 per cent c.i. 0.97 to 1.41), P = 0.096). Mortality after emergency surgery is higher for patients with kidney failure and dialysis is worse than kidney transplantation, with cardiovascular deaths more common than the general population.

8747 Excision of Endometriosis in a Postmenopausal Patient

<h3>Study Objective</h3> We seek to demonstrate endometriosis excision in a postmenopausal patient status post hysterectomy and explore the important clinical features of postmenopausal endometriosis. <h3>Design</h3> Case study. <h3>Setting</h3> Urban academic tertiary care center. <h3>Patients or Participants</h3> One postmenopausal female with history of biopsy proven endometriosis experiencing persistent pelvic pain and deep dyspareunia following prior total laparoscopic hysterectomy and endometriosis excision procedures. <h3>Interventions</h3> Exam under anesthesia, bilateral salpingo-oophorectomy, lysis of adhesions, excision of endometriosis, partial peritonectomy, and cystoscopy. <h3>Measurements and Main Results</h3> Intra-op findings included abundant filmy adhesions and focal hemorrhagic lesions, which appeared consistent with endometriosis. Pathology showed fibrous serosal adhesions and associated hemosiderin laden macrophages compatible with clinical impression of endometriosis, though classical findings of endometrial glands and stroma were absent. The patient reported near complete resolution of her prior symptoms following the surgery, without use of narcotic medication, and overall satisfaction with the procedure. <h3>Conclusion</h3> Endometriosis is an estrogen-mediated chronic inflammatory condition that is benign but has a significant impact on the quality of life of many people. Though symptoms are typically seen in premenopausal individuals, cases of postmenopausal endometriosis have also been shown and are estimated to account for roughly 1-5% of all cases. It is hypothesized that extra-ovarian estrogen production from adipose tissue or endometriosis implants may contribute to or drive these processes, but the precise mechanism and etiology is not well understood. Surgical management is particularly important for postmenopausal patients, especially those with endometriomas, given the increased association with malignancy. Here we present a case of a patient with postmenopausal endometriosis status post TLH who experienced significant symptom improvement following surgical treatment with bilateral salpingo-oophorectomy, partial peritonectomy, lysis of adhesions and excision of endometriosis lesions. More research is needed to fully understand the etiology, impact, and appropriate treatment options for postmenopausal endometriosis.

8244 Laparoscopic Approach to Endometriosis and Fibrosis in the Lateral Pelvic Sidewall

<h3>Study Objective</h3> To explore surgical techniques and anatomic spaces in the sidewall to assist with difficult pelvic sidewall dissections due to endometriosis and fibrosis. <h3>Design</h3> Surgical video. <h3>Setting</h3> Tertiary care hospital. <h3>Patients or Participants</h3> Patient is a 32-yo G0 with pelvic pain and known stage IV endometriosis desiring definitive surgical management. <h3>Interventions</h3> Patient underwent total laparoscopic hysterectomy, right oophorectomy, right ureterolysis and lysis of adhesions. Due to dense right sidewall endometriosis and fibrosis, the medial and lateral pararectal spaces were developed, the ureter was identified, and extensive ureterolysis was performed. Pre-operative ureteral stents were utilized to assist with ureter identification. <h3>Measurements and Main Results</h3> The ureteral stents were removed immediately post-operatively and patient was discharged home the same day. She had an uncomplicated post-operative course with improvement in her pain symptoms. <h3>Conclusion</h3> This video demonstrates the laparoscopic approach to endometriosis within the sidewall and demonstrates safe dissection techniques to avoid injury to key structures.

Robotic Assisted Laparoscopic Excision of a Placenta Percreta

<h3>Study Objective</h3> To illustrate the steps of a robotic-assisted laparoscopic excision of a placenta percreta. <h3>Design</h3> Placenta accreta spectrum (PAS) is a group of disorders characterized by various degrees of placental invasion through the myometrium and uterine serosa. Incidence has increased in recent years following the increase in cesarean deliveries. Risk factors include previous uterine surgeries, multiple cesarean deliveries and the presence of placenta previa. Ultrasound is the primary diagnostic modality. Most PAS cases are diagnosed in the second trimester, and guidelines for early recognition are sparse. A cesarean hysterectomy is the mainstay of management. This video shows an alternative, fertility-sparing treatment for PAS when diagnosed early. <h3>Setting</h3> The video displays a patient in the operating room in the supine position, with Trendelenburg positioning and a bedside assist for robotic-assisted laparoscopy. <h3>Patients or Participants</h3> We present a case of a 32-year-old G5P1121 with a history of one prior cesarean section and a dilation and curettage who was had early imaging concerning for CS scar ectopic and placenta accreta spectrum. <h3>Interventions</h3> The patient was counseled on termination of pregnancy and given her desire for fertility, counseled on attempted resection of invading pregnancy with uterine repair. <h3>Measurements and Main Results</h3> Key surgical steps illustrated include the following: 1. Lysis of adhesions and separation of bladder 2. Identification of the borders of the pregnancy 3. Injection of vasopressin 4. Laparoscopic guided suction dilation and curettage 5. Dissection invading pregnancy 6. Circumferential resection of the invading pregnancy 7. Full thickness myometrial closure in multiple layers <h3>Conclusion</h3> Early diagnosis of placenta accreta spectrum provides options for alternative fertility-sparing treatment.

8778 Laparoscopic Low Anterior Resection of Endometriosis Pelvic Mass with Side-to-End Colorectal Anastomosis

<h3>Study Objective</h3> To perform resection of a recto-vaginal endometriosis mass and end-to-side bowel resection with minimally invasive surgery. <h3>Design</h3> Case study. <h3>Setting</h3> General endotracheal anesthesia. Foley catheter in place. Patient in modified lithotomy with both arms tucked, all pressure points padded and all extremities in neutral position. The patient received preoperative antibiotics and sequential compression devices were placed. The abdomen was prepped and draped in the usual sterile fashion. <h3>Patients or Participants</h3> Patient with endometriosis involving the rectum and vagina desiring minimally invasive surgery. <h3>Interventions</h3> Laparoscopic low anterior resection with side-to-end colorectal anastomosis, trachelectomy, bilateral oophorectomy, lysis of adhesion, flexible sigmoidoscopy, cystoscopy. <h3>Measurements and Main Results</h3> surgery performed without complications; patient recovery was uncomplicated. <h3>Conclusion</h3> We show in this surgical video the possibility to resect a recto-vaginal endometriosis mass and to perform end-to-side bowel resection using minimally invasive surgery without intra-operative or post-operative complications.

8506 Surgical Management of Late 1st Trimester Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> To describe the safe surgical management of late 1^st trimester cesarean scar ectopic pregnancy. <h3>Design</h3> A case report. <h3>Setting</h3> Academic tertiary care hospital. Patient placed in dorsal lithotomy in Trendelenburg position with sponge on ring forceps placed in the vagina. <h3>Patients or Participants</h3> 33-year-old G8P4044 presenting with foul smelling discharge and an LMP 10 weeks prior. Her surgical history is notable for 3 prior cesarean sections and laparoscopic right salpingectomy for ectopic pregnancy. Pelvic ultrasound notable for live intrauterine pregnancy measuring 10 weeks 6 days with complete posterior placenta previa and thin myometrium in lower uterine segment concerning for cesarean scar ectopic pregnancy. <h3>Interventions</h3> Patient was diagnosed with cesarean scar ectopic pregnancy by Maternal Fetal Medicine. She underwent preoperative bilateral uterine artery embolization by Interventional Radiology. She underwent total laparoscopic gravid hysterectomy and left salpingectomy with lysis of adhesions by Benign Gynecology. <h3>Measurements and Main Results</h3> Diagnosis and management of cesarean scar ectopic pregnancy requires multidisciplinary collaboration for safe management. Here, we present a case of a late 1^st trimester cesarean scar ectopic pregnancy managed safely with input from Maternal Fetal Medicine, Family Planning, Interventional Radiology and Benign Gynecology teams. We show the diagnosis of cesarean scar ectopic pregnancythrough transvaginal ultrasound and discuss management options in the late 1^st trimester. We show preoperative bilateral uterine artery embolization. Finally, we show technique for safe lysis of adhesions with low estimated blood loss during laparoscopic total gravid hysterectomy. Final pathology was consistent with intrauterine fetus with placenta accreta. The patient was discharged home on day of surgery without any postoperative complications. <h3>Conclusion</h3> A detailed 1^st TM ultrasound should be considered inpatients who are high risk for cesarean scar ectopic pregnancy. Embolization of bilateral uterine arteries prior to gravid hysterectomy can decrease intraoperative blood loss. A multidisciplinary approach is preferred for management of late 1^st trimester cesarean scar ectopic pregnancies.

Laparoscopic Wedge Resection of a Cesarean Scar Ectopic Pregnancy at Nine Weeks Gestation

<h3>Study Objective</h3> To demonstrate an approach to laparoscopic wedge resection of a cesarean scar pregnancy (CSP). <h3>Design</h3> Video abstract. <h3>Setting</h3> Tertiary care Centre. <h3>Patients or Participants</h3> This case is of a 40-year-old G6P3, with 3 prior cesarean sections who was referred with a possible ectopic pregnancy at 8+3 weeks gestation after presenting with cramping and irregular bleeding. Following admission to hospital, transvaginal ultrasound revealed a CSP and a type 1 placenta percreta with no bladder involvement. The patient wished for fertility-sparing management which was planned to include pre-operative intragestational methotrexate and uterine artery embolization followed by laparoscopic wedge resection. Before pre-operative interventions could be done, the patient experienced acute vaginal bleeding and she was taken urgently for surgical management. <h3>Interventions</h3> Laparoscopic wedge resection of the CSP. <h3>Measurements and Main Results</h3> Laparoscopy revealed bladder adhesions high over the lower uterine segment and the CSP. Wedge resection of the CSP was successfully achieved with restoration of normal anatomy using a systematic approach to lysis of adhesions as well as intraoperative vascular control using dilute vasopressin and pre-emptive skeletonization of the uterine vessels. Surgical blood loss was 100mL. There were no intraoperative or postoperative complications, and the patient was discharged home post-operative day 1. The patient's beta HCG levels returned to normal within one month. <h3>Conclusion</h3> CSPs account for approximately 4% of all ectopic pregnancies. Management is individualized and often requires a multi-modal approach. This case demonstrates a safe and successful approach to fertility-sparing laparoscopic wedge resection.

8979 Laparoscopic Lysis of Adhesions: Adhesiolysis, Enterolysis, and Salpingo-Ovariolysis in a Patient with Infertility

Study Objective To show the surgical steps used to perform adhesiolysis, enterolysis, and salpingo-ovariolys in a patient with a complex surgical history and a desire for pregnancy, planning to undergo in vitro fertilization treatment. Design Step-by-step video demonstration of the technique. Setting A university tertiary care hospital. Patients or Participants A 36-year-old gravida 2 para 0 with an extensive surgical history – including a cholecystectomy with subsequent exploratory laparotomy on post operative day 2 secondary to hematoma formation, and infertility. Interventions Studies have shown that salpingectomy for hydrosalpinx prior to undergoing in vitro fertilization treatment can improve pregnancy rates. In patients with a prior history of abdominal surgery or other inflammatory event, adhesion formation can obstruct access to the pelvis and distort pelvic anatomy, adding increased complexity to the intended procedure. A diagnostic laparoscopy with adhesiolysis, enterolysis, and salpingo-ovariolysis is performed prior assessing the integrity of the fallopian tubes and ultimately performing bilateral salpingectomy with the aim to improve in vitro fertilization success rates. Measurements and Main Results We discuss three important issues related to lysis of adhesion. First, preoperative and intraoperative considerations regarding abdominal entry and trocar placement. Second, guidelines for lysing specific types of adhesions are discussed, including technique and use of ultrasonic energy. Finally, management of sequela of adhesion lysis such as bowel injury, fallopian tube damage, and obtaining hemostasis are discussed. At postoperative follow up, the patient had healed well and was referred back to reproductive endocrinology to start in vitro fertilization treatments. Conclusion It can be difficult to know preoperatively the extent of adhesive disease in a patient with prior abdominal surgery. Preoperative review of imaging, history, and prior operative reports can help in planning entry. Visualization and skilled intra-operative surgical technique are necessary to perform safe adhesiolysis, enterolysis, and salpingo-ovariolysis. To show the surgical steps used to perform adhesiolysis, enterolysis, and salpingo-ovariolys in a patient with a complex surgical history and a desire for pregnancy, planning to undergo in vitro fertilization treatment. Step-by-step video demonstration of the technique. A university tertiary care hospital. A 36-year-old gravida 2 para 0 with an extensive surgical history – including a cholecystectomy with subsequent exploratory laparotomy on post operative day 2 secondary to hematoma formation, and infertility. Studies have shown that salpingectomy for hydrosalpinx prior to undergoing in vitro fertilization treatment can improve pregnancy rates. In patients with a prior history of abdominal surgery or other inflammatory event, adhesion formation can obstruct access to the pelvis and distort pelvic anatomy, adding increased complexity to the intended procedure. A diagnostic laparoscopy with adhesiolysis, enterolysis, and salpingo-ovariolysis is performed prior assessing the integrity of the fallopian tubes and ultimately performing bilateral salpingectomy with the aim to improve in vitro fertilization success rates. We discuss three important issues related to lysis of adhesion. First, preoperative and intraoperative considerations regarding abdominal entry and trocar placement. Second, guidelines for lysing specific types of adhesions are discussed, including technique and use of ultrasonic energy. Finally, management of sequela of adhesion lysis such as bowel injury, fallopian tube damage, and obtaining hemostasis are discussed. At postoperative follow up, the patient had healed well and was referred back to reproductive endocrinology to start in vitro fertilization treatments. It can be difficult to know preoperatively the extent of adhesive disease in a patient with prior abdominal surgery. Preoperative review of imaging, history, and prior operative reports can help in planning entry. Visualization and skilled intra-operative surgical technique are necessary to perform safe adhesiolysis, enterolysis, and salpingo-ovariolysis.

Management of Native Lung Malignancy in a Lung Transplant Recipient.

A 75-year-old male patient with a history of previous right lung transplant presented with left upper lobe squamous cell carcinoma. Endobronchial ultrasound and positron emission tomography displayed no mediastinal lymphadenopathy. A ventilation-perfusion scan displayed minimal perfusion to the native lung. Left robot-assisted lysis of adhesions, decortication, left upper lobectomy, and mediastinal lymphadenectomy were performed. The patient tolerated the procedure well. Final pathology displayed pT2a, n0, m0. Lobectomy is a safe and efficient treatment of native lung malignancy in the setting of previous lung transplant with minimally functioning native lung.

Ureterolysis for Deep Infiltrating Endometriosis Using Indocyanine Green on the Robotic Platform

<h3>Study Objective</h3> To demonstrate safe identification of ureters in patients with deep infiltrating endometriosis or severe adhesive disease using indocyanine green under near-infrared fluorescence on the robotic platform. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> A 43-year-old G0 with stage IV endometriosis presented with chronic pelvic pain. Her surgical history is notable for two aborted hysterectomies due to severe adhesive disease, despite extensive lysis of adhesions. She desired surgical intervention. <h3>Interventions</h3> In cases of stage IV endometriosis, localizing the ureters can be challenging due to severe adhesive disease, surrounding fibrotic tissue, and distorted anatomy. Intravenous indocyanine green has previously been described to assist with resection of endometriosis.^1-3 Alternatively, we describe a technique that allows for easier identification of ureters using indocyanine green (ICG) injection retrogradely in ureteral stents while visualized under near-infrared fluorescence (NIRF).^4-5 1. Perform cystoscopy and place bilateral open-ended 5-French ureteral catheters. Inject indocyanine green retrogradely in each ureteral catheter, and place caps to seal the catheters to maximize ICG retention. 2. Once robotic-assisted laparoscopic surgery is started, use NIRF to identify the ureter. The ureter will emit green fluorescence, whereas the surrounding tissue will not. 3. Once the ureter is identified, NIRF is intermittently used to safely follow the course of the ureter and perform ureterolysis, while excising endometriosis. <h3>Measurements and Main Results</h3> The patient underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, low anterior bowel resection with primary anastomosis, and resection of endometriosis without intraoperative complications or ureteral injury. Her postoperative course was unremarkable. At her 3-week postoperative visit, pelvic pain had completely resolved. <h3>Conclusion</h3> This case demonstrates the use of intra-ureteral ICG and NIRF to identify the ureters and perform ureterolysis in cases of deep infiltrative endometriosis.

8356 Robotic Surgery: Pelvic Mass Excision, Resection of Non-Communicating Uterine Horn, and Fulguration of Endometriosis

<h3>Study Objective</h3> To demonstrate surgical techniques for approaching an advanced case of endometriosis in a patient with a congenital uterine anomaly, large pelvic mass, and severe adhesive disease. <h3>Design</h3> A step-by-step explanation of the surgery. <h3>Setting</h3> Community Based Teaching Hospital, Operating Room. <h3>Patients or Participants</h3> 33-yo G0 with known unicornuate uterus with non-communicating uterine horn, dysmenorrhea, suspected endometriosis, infertility, congenital absence of right kidney. <h3>Interventions</h3> Chromotubation was first performed to evaluate if the patient had patent fallopian tubes. The pelvic mass was then decompressed and drained revealing multiple right ovarian cysts. Anatomical landmarks were identified with a retroperitoneal dissection and extensive lysis of adhesions. The bladder was backfilled intermittently to help identify surgical planes. A Keith needle was temporarily placed in the abdomen to elevate the pelvic mass and aid in visualization. The pelvic mass and non-communicating uterine horn were resected. Hemostasis was achieved with electrocautery and suturing. Endometriotic implants in the pelvis and diaphragm were fulgurated and an appendectomy was performed due to extensive damage from endometriosis. All specimens were placed in a bag and removed through the umbilical port site. Post-operatively, the patient was started on progesterone therapy. <h3>Measurements and Main Results</h3> Successful completion of surgery, no complications, the patient reported improvement in her symptoms. <h3>Conclusion</h3> When dealing with severe adhesive disease, abnormal anatomy, and limited space due to a pelvic mass it is key to approach these cases in a stepwise fashion. Visualization can be optimized via temporary measures such as using a Keith needle. If irregular anatomy is noted, landmarks can be identified via the retroperitoneal dissection.

How to do repeat hepatectomy for remnant liver recurrence using diaphragmatic incision for right liver mobilization.

In addition to difficulties with parenchymal resection reflecting anatomic disorientation arising from rotation of the liver remnant that accompanies regeneration, repeat resections typically involve difficult and protracted lysis of adhesions. We describe our technique for facilitating right liver mobilization even in the presence of severe adhesions. Lysis of dense retroperitoneal adhesions posterior to the right liver can be performed safely by incising the diaphragm to facilitate manipulations to mobilize the right liver.

Complex Abdominal Wall Reconstruction with Biologic Mesh for Ventral/Umbilical Hernias in Patients with Cirrhosis

Introduction: Patients with cirrhosis undergoing non-liver transplant surgery have a higher risk of adverse events than those without cirrhosis. Methods: This study had retrospective and prospective components, including all cirrhotic patients at our center with complex abdominal wall reconstruction (CAWR) for ventral/umbilical hernia repair with biologic mesh between December 2016 and November 2021. Results: We studied 37 patients with cirrhosis. Their mean age was 57.2 years. 64.9% were male. The median BMI was 28.1 kg/m2. Ascites was present in 83.3% of patients. The other most common comorbidities were alcohol abuse (67.6%), hypertension (37.8%), and diabetes (24.3%). All complications in aggregate occurred in 11 patients (29.7%). Six patients (16.2%) underwent reoperation. Surgical site infection (SSI) occurred in 5 patients (13.5%). Four deaths occurred within 90 days (11.2% cumulative mortality). By 120 days, there were 5 deaths (14.2% mortality, but none due to the operation). Three predictors (mesh size ≥200 sq cm, lysis of adhesions, and VHWG grade ≥3) achieved an area under the receiver operating characteristic curve (AUROC) for SSI of 0.938 and two predictors (BMI ≥35 kg/m2 and preoperative aspirin) yielded an AUROC of 0.825 for 120-day mortality. Conclusion: Our results suggest that CAWR for ventral/umbilical hernias among cirrhotic patients is feasible given a dedicated CAWR team in collaboration with transplant surgeons and a transplant hepatologist. The rates of adverse outcomes were low or at the midpoint of the range of the study-specific estimates.

Malrotation in Adult Patients and Associated Outcomes: A Single Institution Review

INTRODUCTION: Malrotation classically presents with bilious emesis in children and can be life-threatening. Data on adults with malrotation is lacking. METHODS: In a single institution, retrospective 20-year data collection, adult patients (>18 years) with malrotation were included. We evaluated demographics, presentation, pre- and postoperative course, and short- and long-term outcomes. Descriptive statistics are presented. RESULTS: All 17 patients (average age 42 ± 16, 76% white, 65% female, 41% Medicare/Medicaid) with malrotation underwent surgery. No patients presented with bilious emesis, but 94% presented with abdominal pain, 12% chronic (>1 year), and 70% with abdominal pain and nonbilious emesis. Approximately 24% had additional studies (upper gastrointestinal series, x-rays) before CT scan which confirmed the diagnosis. Delay to operative exploration was identified in 65% with a wide range of timing (2 weeks to 3 years). Subgroup analysis showed 35% having surgery within 1 week of diagnosis. Adult surgeons performed 65% of the operations. Laparoscopy was completed in 18%, and 82% were open. Postoperative ileus (average 7 days ± 1.4) was noted in 41% of patients. Readmission rate was 24% and 6% required reoperation for lysis of adhesions. The majority of patients with follow-up had resolution of pain (88%). CONCLUSION: In the largest series of adult patients with malrotation, atypical presentations with abdominal pain rather than bilious emesis were ubiquitous, requiring CT scan for diagnosis. Delayed repair was common by both adult and pediatric surgeons. Preference tended to open approach. Although postoperative ileus was prevalent, most patients had resolution of abdominal pain at postoperative follow-up.

V-014 OPEN REPAIR OF PRIMARY LUMBAR HERNIA WITH PREPERITONEAL MESH

Abstract This video presents an open repair of a primary lumbar hernia with preperitoneal mesh performed at a high-volume hernia center. The patient was a 71-year-old female referred due to chronic pain from a primary hernia of the right superior lumbar triangle. The patient was positioned in the left lateral decubitus position with the bed slightly flexed. A skin incision was created sharply, and electrocautery used to dissect subcutaneous tissue and superficial fascia, revealing the hernia contents. Circumferential lysis of adhesions was performed with blunt and cautery dissection to release the hernia contents from the abdominal wall. Once the hernia contents were mobilized, they were then carefully reduced through the fascial defect. The hernia defect measured approximately 3.5×3.5 cm. Next, the preperitoneal space was circumferentially developed. This was done primarily with blunt finger dissection, using a rolling motion to direct pressure towards the abdominal wall and sweep the peritoneum and other attachments down. Larger attachments are gently retracted and divided with electrocautery. The preperitoneal space was measured at 20×19 cm and the mesh trimmed to those dimensions. The mesh was carefully laid flat in the preperitoneal space. No mesh fixation was required. Fascial edges were dissected free for 1–2cm surrounding the defect. Two running 1–0 PDS sutures were used to close the hernia defect. A closed-suction drain was placed superficial to the fascia to minimize seroma formation. The superficial fascia and dermis were closed in layers. The patient had a routine hospital course and was discharged on post-operative day 3.