SLS Conference Overview

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Dr. Larry Demco: "This is Dr. Demco doing a synopsis of the 4^th Annual World Symposium on New Diagnostic Techniques in Microlaparoscopy, which was held in Miami, Florida on February 25^th and 26^th of the year 2000. The conference was sponsored by the Society of Laparoendoscopic Surgeons (SLS), and the course director was Dr. Lawrence A. Demco from Calgary, Canada. The faculty included Dr. Carlos Gracia from California, Dr. James Carter from Mission Viejo, California, Dr. Peter Geis, a general surgeon from Baltimore, Dr. Kuster from La Jolla, California, and Dr. Almeida from Mobile, Alabama.

It was a two-day conference in which the first day was basically a session with videos didactic teaching by each of the faculty members, including a hands-on inanimate lab to deal with the techniques of microlaparoscopy. The opening remarks and the initial introduction were given by Dr. Demco, who went over the need for microlaparoscopy and defined the technique. This included explanation of what microlaparoscopy is, and the forms of laparoscopy done with smaller instruments – 2-mm and 3-mm versus the conservative 4-mm, 5-mm, up to 10-mm instruments. He also went over the scope of microlaparoscopy being done during general anesthesia, versus doing it on an awake patient.

After his opening remarks, Dr. Jim Carter went on to speak about the anesthetic required for doing laparoscopy under local. He went over the various agents, their complications and side effects, as well as the need for the monitoring of IV conscious sedation – the how-to’s and what is appropriate and needed according to the American Association of Anesthesiologists Symposium. This was followed by Dr. Peter Geis, and he talked about the various techniques that are used to insert the trocar in an awake patient and how it varies with the patient who is under general anesthetic. He also went over the various alternative sites and how to locate these sites in case of the possibility of adhesions.

The conference then changed course to actually apply the techniques of local anesthetic. Dr. Demco proceeded to talk about the technique of pain mapping. This is a technique in which the patient is awake and is able to view the monitor. The surgeon and the patient work together as a team to determine the source of the pain, find where it is located, and pinpoint its borders – find where it starts, find where it ends, and actually map out the area needed for treatment. This technique was initially applied to patients with pain from non-previous diagnoses. This has moved on to the same mapping technique for the diagnosis and proper therapy for endometriosis.

Following this talk, Dr. Almeida then went over the different aspects needed to actually perform laparoscopy in the office setting. He went over the instruments available, and he also talked about the actual set up in the office – how it would be different – and the instruments that are needed in the general operating room. He showed us that there are various ways to cut corners and lower costs. He also dealt with the issue of reimbursement.

The conference broke for lunch to view the various sponsors that were at the conference and see some of the new instruments that were available for microlaparoscopy. The conference then proceeded into the afternoon session, and Dr. Demco opened this session with a talk on how microlaparoscopy can be used to determine the pain associated with adhesions. He tried to demonstrate with the patient awake which adhesions hurt and which ones didn’t so that the appropriate therapy would be carried out. He then went on to show how pain is referred in the pelvis by using pain mapping. We were able to determine that not all patients have right-left orientation – in fact, approximately 18% of patients have opposite orientation – and that 35% of pain is referred.

Following this, Dr. Carlos Gracia then gave a very interesting talk about microlaparoscopy and its relationship to general surgery and also to vascular surgery. He went over some of the robotics that are now available to aid laparoscopy and the need for microlaparoscopy in this particular discipline of surgery. He also went on to talk about microlaparoscopy’s applications in general surgery to the treatment of gallbladder disease and how to do Nissen fundal plication using microscopic instruments.

The final session prior to the lab break was led by Dr. Kuster, who gave an overview of all the different types of pathology one can see in the abdominal cavity. This view is different through a smaller scope, and he gave an excellent presentation on how the various pathologies would look and what to recognize, then he covered some general information. This information was informative to both the general surgeons and to the gynecologists that were present.

Finally, the afternoon finished with an inanimate lab in which a company by the name of Limbs & Things provided excellent models that portrayed the difficulties associated with microlaparoscopy. These involve finding your way through the bowel and behind the uterus, tubes, and ovaries using very little gas distension, which is critical to successful laparoscopy under local anesthetic. These techniques were demonstrated quite extensively, and the participants finally did catch on, as the lab impressed us to the need to demonstrate how microlaparoscopy is different from general laparoscopy.

The following day, the conference went on to include video presentations. Each of the faculty members then presented their interesting videos and explained how microlaparoscopy applied to them. This was extremely interesting because enough time was given to the videos, and discussion ensued. The actual technique of Nissen fundal plication was reviewed – how to approach this using microscopic instruments versus more microscopic instruments, and how it can actually aid in reducing post-operative pain, discomfort, and cosmetics. The other videos showed the appropriate setup for microlaparoscopy in the ICU, the equipment needed, the technique, as well as some microlaparoscopy used with the awake patient in the emergency room.

The final presentation and videos, which were extremely interesting, were given by Dr. Douglas Ott, from Macon, Georgia. He presented an interesting concept concerning how to decrease shoulder pain associated with laparoscopy. He gave an interesting presentation and video on how heated and humidified gas plays an important role in reducing the cellular death – which is now associated with the cause for the shoulder pain that we see after laparoscopy – and how heating and humidifying the gas can reduce this.

The discussion between the people attending was positive, overall. There was a free flow of information with each of these video sessions, as everyone tried to sort out what was different with each technique presented and figure out how they could adapt them to their particular needs, whether they were general surgeons or gynecologists. Having a society that has general surgeons, urologists, and gynecologists in the same room together reviewing videos and techniques really adds insight and a diversified exchange of ideas, which benefited all specialties and had involved everybody by the end of the conference. Following this presentation, several of the faculty, including some of the attendees, were interviewed for their impressions of the conference and talked about various topics of microlaparoscopy. Thank you."