2023 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Montréal, Canada, 19 March–April 1 2023: Video Loop

Abstract

V123 Right Adrenalectomy for Isolated Renal Cell Cancer Metastasis After Left Adrenalectomy and Left Nephrectomy for Initial Treatment James Drake, MD; Chandler Wilfong, MD; University of Illinois College of Medicine Peoria This video demonstrates robotic right adrenalectomy. The patient had a left renal cell carcinoma treated with left nephrectomy and left adrenalectomy. Later, he was incidentally found to have an isolated metachronous 1.6 cm metastasis to the right adrenal gland that required right adrenalectomy for curative resection. We perform right adrenalectomy with a robotic approach. Minimally invasive adrenalectomy for metastatic lesions of this size has well established benefits including faster recovery, less pain, and less bleeding without compromising oncologic outcomes. The patient required hormone replacement with 0.1 mg fludrocortisone daily and 30 mg hydrocortisone daily, and had no postoperative complications. V124 Morgagni Hernia: A Robotic Preperitoneal Mesh Repair Brandon M Smith, MD; Brandon Grover, DO, FACS, FASMBS; Gundersen Health System The patient is a 71-year-old male who presented to surgery clinic for elective repair of an incarcerated Morgagni hernia. Prior to clinic presentation he had a several month history of right pelvic pain. Work-up included CT scan which identified a 4.0 cm right common iliac artery aneurysm which was managed with endovascular stent. An incidentally found Morgagni hernia containing small bowel and colon prompted surgical referral. He was asymptomatic from his hernia, denied chest pain, shortness of breath, reflux, dysphagia, or nausea. He underwent a robotic repair of the Morgagni hernia with preperitoneal placement of mesh. His post-operative course was uneventful. V125 Laparoscopic Wedge Resection for Gastric GIST Assisted with Intraoperative Gastroscopy Ana Chavez Monarrez, MD; Luis Leal Del Rosal, MD; Ayermin Vargas Salgueiro, MD; Christus Muguerza Del Parque We present a case of a Gastric GIST treated by Laparoscopic Wedge Resection with excellent postoperative and oncologic results. The patient is a 39-year-old male who starts with melena. A 5 cm submucosal tumor was found at the endoscopy, we performed a laparoscopic wedge resection with intraoperative gastroscopy. A 5 cm gastric incision was made and removed the tumor at the base with a linear stapler, the operative time was 58 min. Pathology results in a low-grade GIST tumor with free surgical margins. Was discharged on the 2nd day with a liquid diet and progressed on the 4th day to a normal diet. V126 Nissen Fundoplication Takedown to Laparoscopic Sleeve Gastrectomy Yannis Raftopoulos, MD, PhD, FACS, FASMBS; Shruthi Rajkumar, MD; Michael Bell, PAC; Elana Davidson, PAC, MPAS; Holyoke Medical Center This is a state-of-the-art performance of a Nissen fundoplication takedown to a laparoscopic sleeve gastrectomy. In this video, we aim to share our approach to the fundoplication takedown. Our goal is to discuss the fundamental steps that can ensure a successful takedown to proceed with a gastrectomy. Other key aspects of this video are our no-bougie approach to sleeve gastrectomy and gastropexy. In addition, we performed a posterior hiatal hernia repair after the takedown to prevent reflux. V128 Robotic-assisted Pre-Peritoneal Repair of Morgagni Diaphragmatic Hernia Michaela Simoncini; Hazem Shamseddeen, MD; Peter Cmorej, Alexandra Johns, MD; Nicole N Moore, MD; UC Davis The patient is a 35-year-old man with Hemophilia A and rectal cancer status-post neoadjuvant chemoradiation and abdominoperineal resection, then subsequent microwave ablation and systemic therapy for liver metastases. During chemotherapy, he had frequent chest pain with negative cardiac workup which was later contributed to his Morgagni hernia. He was counseled to repair his Morgagni hernia due to 10% risk of incarceration. His chemotherapy was held three weeks preoperatively, and he received additional recombinant factor eight perioperatively. He underwent robotic-assisted pre-peritoneal hernia repair with mesh and discharged home on post-operative day 2 without complications or further episodes of chest pain. V130 Acute Bowel Obstruction from Suspected Intraluminal Hematoma after RNY Gastric Bypass Amelia Lucisano, MD, MS; Christopher Le, MD; William Hope, MD; Douglas Reed, MD; Bestoun H Ahmed, MD, FACS, FRCS, FASMBS, ABOM; UPMC Intraluminal hematoma is a rare cause of acute bowel obstruction after gastric bypass, however it must be addressed promptly to avoid numerous serious complications. Our video demonstrates the case of an early acute bowel obstruction at the level to the JJ anastomosis. Intra-operative footage clearly details the point of obstruction from a likely intraluminal hematoma. By milking the hematoma down the common channel and into the cecum, we were able to resolve the obstruction and the patient recovered without any significant complications. V131 Bile Duct Injury During Laparoscopic Cholecystectomy Kuldip Singh, Dr; Ludhiana Laparoscopic Surgical Centre bile duct injury during laparoscopic cholecystectomy still remains a matter of concern. Majority of the BDIs occur because of misidentification of CBD, CHD, RHD as the cystic duct. These videos demonstrate the surgeons getting into an error trap of misidentification of the ductal anatomy leading to classical Davidoff CBD injury, further leading to injury to the common hepatic duct. Another videos shows injury to the subvesical duct and right hepatic artery. Application of critical view of safety would have saved these injuries. V132 Leak After Primary Repair of Perforated Gastric Ulcer Tristan Seton, MD; Matthew J Billy, DO; Alexandra Falvo, MD, FACS; Ryan Horsley, DO, FACOS, FASMBS; Geisinger Community Medical Center A 67 year old woman with history of smoking presented to an urgent care with hematemesis, epigastric pain, and anemia due to a perforated gastric ulcer diagnosed on EGD and CT. She subsequently underwent laparoscopic primary repair of the ulcer. She was found to have a leak on post operative day #2 and she returned to the operating room for laparoscopic subtotal gastrectomy with Roux en Y reconstruction, hiatal hernia repair, and bilateral truncal vagotomy. No further leak was seen on additional imaging and the patient was discharged home tolerating a gastric bypass stage 2 diet. V133 Laparoscopic Reduction of Type IV Hiatal Hernia after Esophagectomy and Gastric Pull-Through Andrea R Foster, MD 1; Timbre Backen, DO1; Ashwin Kurian, MD2; 1Swedish Medical Center; 2Denver Esophageal & Stomach Center Introduction: The purpose of this video submission is to demonstrate the operative steps involved in a hiatal hernia repair several years after the patient underwent esophagectomy. Methods and Procedures: This is a case report consisting of surgical videos with audio explanation collected after patient discussion and consent. Results: This patient underwent successful hiatal hernia repair several years after esophagectomy and ultimately returned to her preoperative baseline. Conclusions: A hiatal hernia repair after an esophagectomy is a technically intricate procedure that can be completed in a safe and efficient manner. V134 Robotic Transthoracic Diaphragmatic Hernia Repair: A “State of the Art” Video Case Report Ila Sethi; Ankit Dhamija, MD; Division of Cardiothoracic Surgery, Department of Surgery, Stony Brook University Hospital This video abstract highlights the case of a 59-year-old female with Stage IV Hepatocellular Carcinoma status post Portal Vein Embolization and subsequent Right Hepatic Lobectomy with possible hemi-diaphragmatic defect who presented with refractory shoulder, flank, and abdominal pain. She was found to have evidence of diaphragmic hernia on CT scan. A robotic transthoracic approach was chosen in light of this patient’s prior abdominal surgical history. The herniated colon was able to be placed into the abdomen and the diaphragmatic defect was repaired using a Gore Tex graft. On follow-up, the patient reported significant pain relief, increased appetite, and weight gain. V135 Robotic Resection of Gastric Gastrointestinal Stromal Tumor Near Gastroesophageal Junction Sarah E Pivo, MD; Miguel Burch, MD; Cedars Sinai This video presents a 60yo female with a gastric gastrointestinal stromal tumor (GIST) in the cardia of the stomach encroaching on the gastroesophageal junction (GEJ) who presented with hemorrhage. She was treated with neoadjuvant imatinib for hemorrhage control and to reduce size of tumor for anatomic preservation. She underwent robotic resection of tumor with two-layer hand-sewn repair of gastrotomy and fundoplication. The technique of GEJ reconstruction and marking tumor margins with combined endoscopic/robotic visualization is demonstrated. The technique enabled preservation of gastric wall for reconstruction without narrowing the GEJ. Final pathology revealed negative margins and the patient had no post-operative dysphagia/reflux. V136 Utilization of Indocyanine Green (ICG) Guidance During Robotic Retroperitoneal Adrenalectomy Mohammed Elshamy, MD 1; Eren Berber, MD2; 1Stony Brook University; 2Cleveland Clinic Foundation Here we present the utilization of ICG fluorescence during robotic retroperitoneal adrenalectomy. This is a 50-year-old male diagnosed with primary hyperaldosteronism during workup for longstanding hypertension and hypokalemia. Imaging demonstrated a 3.3 cm left adrenal adenoma. Intraoperatively, after establishing retroperitoneal access, ICG was injected intravenously, aiding in the identification of the borders of the adrenal gland from the surrounding fat utilizing near-infrared fluorescence technology. this assists in guiding the dissection of the adrenal gland to ensure a complete resection. The patient was discharged POD1 with normalization of aldosterone and direct renin levels and remained off antihypertensives at 6 weeks. V137 Robotic Roux-En-Y Gastric Bypass Wendy S Li, MD; Dimitrios Stefanidis, MD, PhD; Indiana University School of Medicine This video demonstrates a "state-of-the-art" robotic Roux-en-y gastric bypass procedure in a patient with morbid obesity. It demonstrates the steps of the operation including the creation of the gastric pouch, division of omentum, identification of ligament of Treitz, measurement of the small bowel to create the appropriate length biliopancreatic and Roux limbs, creation of jejuno-jejunal anastomosis and hand sewn gastro-jejunal anastomosis with closure of the mesenteric and Petersen's defects. Importantly, it provides technical tips that can help surgeons enhance the performance of this procedure. The final endoscopy ensures that there's no leak and good hemostasis at the anastomosis. V138 Successful Robotic Repair of Gastro-gastric Fistula Following Roux-en-y Gastric Bypass Justin Dhyani, MD; Jordan Purewal, MD; Seth Kipnis, MD, FACS, FASMBS; Jersey Shore University Medical Center We present a case of a 53 year-old-female with a history of roux-en-y gastric bypass performed 12 years prior, who presented to the clinic with weight regain. Patient presented with a BMI of 53. Patient was sent for EGD and UGI which diagnosed gastro-gastric fistula. A robotic gastrectomy was performed, which removed the fistulized portion of the gastric pouch and a majority of the gastric remnant. The patient was discharged home on post operative day 1. At one month follow up, patient reported no complications and had lost 42 lbs reducing her BMI from 53 to 45. V140 Robotic Hepatic Cyst Drainage and Fenestration Niteesh Sundaram, MD, MS; Daniel W Kim, MD; Praveen Satarasinghe, MD, MBA; Thomas Butler, MD; Sunny Fink, MD; Crozer Chester Medical Center We present a case of a long-standing, increasingly symptomatic hepatic cyst in a 63-year-old woman. On computed tomography, our patient had evidence of a simple hepatic cyst, measuring 11.0 cm (cm) by 8.7 cm by 11.1 cm, resulting in elevation of the right hemidiaphragm and subsequent compression of the right lung. The patient endorsed worsening shortness of breath and the decision was made to perform a robotic hepatic cyst drainage and fenestration. The procedure was successful and final cytology showed no evidence of malignancy. On follow-up, the patient stated that her shortness of breath has markedly improved. V141 Robot-assisted Laparoscopic Rectopexy, Sacrocolpopexy and Cystoscopy Tamar Sherman; Nathan Cheng; Debra Fromer; Michael Stifelman; Stephen Pereira; Hackensack University Medical Center We present a Robot-assisted laparoscopic Rectopexy, Sacrocolpopexy and Cystoscopy secondary to pelvic organ and complete rectal prolapse. This patient is an 86 year old female that developed an introital bulge and high grade cystocele. Additionally, she presented with a rectal prolapse complicated by fecal incontinence. The patient was offered conservative management including a pessary to manage her pelvic organ prolapse, however, she ultimately elected for a combined Rectopexy and Sacrocolpopexy with Urogynecology and General Surgery. V142 Incomplete Malrotation Encountered During Robotic-Assisted Roux-en-Y Gastric Bypass Mitchell A Rice, MD; Colin G Harris, BS; Brittany S Kern, MD; Indiana University/IU Health A 33 year-old female with a history of obesity and GERD presented for evaluation for bariatric surgery. Pre-operative EGD was significant for a hiatal hernia so the patient was scheduled for Roux-en-Y gastric bypass surgery and hiatal hernia repair. Intra-operatively the case was complicated by an incidental partial malrotation requiring deviation from standard Roux-en-Y procedure to accommodate the patient's abnormal anatomy. Her post-operative course was complicated by anastomotic swelling that resolved with steroid and anti-emetic therapy. V143 Bypass Reversal with Feeding Tube in Preserved Roux Limb Karl Hage 1; Ishna Sharma1; Marita Salame1; Travis McKenzie1; Benjamin Clapp2; Barham Abu Dayyeh3; Omar M Ghanem1; 1Department of Surgery, Mayo Clinic Rochester, MN.; 2Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX; 3Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA We describe the case of a 70-year-old female with a history of Roux-en-Y gastric bypass. She presented with a BMI of 13.1 kg/m2, diarrhea and signs of malnutrition. We elected to do a gastric bypass reversal. After resection of the proximal roux limb and reestablishment of the gastro-gastrostomy, we preserved the distal roux limb and placed the feeding tube directly inside it. This approach allowed us to avoid potential complications of J-tube such as obstruction and bile leakage while establishing a feeding route. Follow-up at 5 months was optimal, showing that this novel approach is feasible with good outcomes. V144 Bouveret’s Syndrome with Incidental Gallbladder Adenocarcinoma Min Yun Ho, Dr; Eugene Lim, Dr; Ye Xin Koh, Dr; Zhen Jin Lee, Dr; Jeremy Tan, Dr; Weng Hoong Chan, Dr; Hock Soo Ong, Dr; Wai Keong Wong, Dr; Chin Hong Lim, Dr; Alvin Eng, Dr; Nan Guang Tan, Dr; Tiffany Lye, Dr; Singapore General Hospital We present a rare case of Bouveret's syndrome with gallbladder adenocarcinoma. 62-year-old Chinese gentleman presents with vomiting, inability to eat and weight loss. On examination, abdomen was distended and succussion splash present. Esophagogastroduodenoscopy revealed gallstone causing gastric outlet obstruction. Endoscopic removal of the gallstone was unsuccessful. Computed-tomography abdomen and pelvis showed that cholecysto-duodenal fistula had formed. A suspicious sections 4/5 liver mass at the gallbladder fossa was seen. The video not only shows meticulous laparoscopic techniques but also goes through the thought process behind managing a complex case. In Bouveret's syndrome with suspected gallbladder carcinoma, radical cholecystectomy should be considered. V145 Robotic Large Paraesophageal Hiatal Hernia Repair with Toupet Fundoplication Michelle Dugan; Sharona Ross; Tien Nguyen; Iswanto Sucandy; Alexander Rosemurgy; Digestive Health Institute Tampa This video demonstrates a robotic paraesophageal hiatal hernia repair with topupet fundoplication. A 81-year-old woman presents with a history of GERD and extended PPI use. Preoperative EGD showed large paraesophageal hiatal hernia and UGI showed one stripping wave. The fundoplication was undertaken without any complication 10-French flat JP was placed into the mediastinum. Intraoperative EGD confirmed the fundoplication was robust. The patient tolerated the operation well and was discharged on day one. V146 Rare Case of Large Insulinoma Unmasked After Sleeve Gastrectomy Dosuk Yoon, DO 1; Alexis Bell2; Christopher Engler, DO1; Leaque Ahmed, MD1; 1Wyckoff Heights Medical Center; 2St. George's University We present a rare case of large insulinoma that is unmasked one month after sleeve gastrectomy, which the patient presented with neuroglycopenic symptoms and hypoglycemia. CT scan demonstrated 7-cm exophytic mass lesion at pancreatic tail, and the patient underwent laparoscopic distal pancreatectomy. Intraoperatively, the mass was distal to inferior mesenteric vein. Therefore, we elected to proceed with spleen sparing distal pancreatectomy, and the mass was confirmed a well differentiated insulinoma. We hypothesize that the insulin resistance from morbid obesity was masking the hyperinsulinemic state which was exposed after lower caloric intake and improved insulin sensitivity after sleeve gastrectomy. V147 Laparoscopic Enteropexy for the Treatment of Jejunojejunal Intussuception Following Laparoscopic Roux-en-Y Gastric Bypass Abdullah Almunifi, MD1; Félix Thibeault, MD, FRCSC 2; Alexis Deffain, MD2; Wael Dimassi, MD2; Heba Alfaris, MD3; Adam Di Palma, MD, FRCSC2; Anne-Sophie Studer, MD2; Ronald Denis, MD, FRCSC, FASMBS2; Pierre Y Garneau, MD, FRCSC, FASMBS2; Radu Pescarus, MD2; 1Department of Surgery, College of medicine, Majmaah University, Saudi Arabia; 2Division of Bariatric Surgery, Department of Surgery, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada.; 3Department of Metabolic and Bariatric Surgery, King Saud Medical City, Riyadh, Saudi Arabia The reported incidence of jejunojejunal intussusception following LRYGBP is 0.4–0.7%. We report the case of a 37-year-old female who underwent LRYGB 4 years prior. Following her presentation with LUQ pain, a CT scan was performed and showed an intussusception at the jejunojejunal anastomosis. Upon laparoscopic exploration a possible antegrade & retrograde intussusception at the jejunojejunal anastomosis was diagnosed. Interestingly, one other spontaneous unrelated intussusception site was present within the terminal ileum. This video shows our laparoscopic enteropexy technique for both the alimentary and common limbs of the jejunojejunostomy. The patient recovered well, was discharged PO#1 and denies any symptoms at 6-month follow-up. V148 Robotic Transversus Abdominus Release Alice C Gamble, DO; Creighton University—Phoenix Alliance This is video for a 46 year female patient with a large ventral incisional hernia extending into the subxiphoid region who underwent a robotic transversus abdominus release (TAR) with macroporoous monofilament polypropylene mesh. The video aims to demonstrate key anatomic landmarks of TAR and showcase the critical view of TAR. The patient's postoperative course was complicated by a MSSA mesh infection, mesh salvage was successful in this patient without evidence of recurrence on routine 4 month post operative follow up. V149 Robotic Approach to Recurrent Hiatal Hernia and Delayed Gastric Emptying Lorna A Evans, MD; Alvaro Ducas, MD; Rocio Castillo-Larios, MD; Michel Cordies, MD; Enrique F Elli, MD, FACS; Mayo Clinic 52-year-old patient with a history of robotic hiatal hernia repair with vicryl mesh in October 2020 performed at another institution. This patient presents to the clinic in February 2021 with gastroparesis, dysphagia to solid foods, nausea, vomiting and regurgitation. An esophagram shows failure of a previous fundoplication and recurrence of the slipped hiatal hernia. Upper EGD shows eosinophilic esophagitis in the middle third of the esophagus, grade B esophagitis according to the Los Angeles classification in the lower third, and hiatal hernia. V150 Robotic-Assisted Laparoscopic Excision of GIST at the GE Junction with Hiatal Hernia Repair Jasmine B Beloy, DO, MSMEd; Karolin Ginting, MD; Caitlin Hardin, DO; Shyam Allamaneni, MD; The Jewish Hospital Gastrointestinal stromal tumors (GISTs) located at the gastro-esophageal (GE) junction and the esophagus are rare (0.5%). GISTs at these locations pose technical challenges and often require hybrid laparoscopic-endoscopic resection to avoid esophagectomy while achieving adequate margins. Here we present a case of an 84-year-old female who presented with melena and associated anemia. Work-up revealed a large mass projecting into the gastric lumen at the region of the GE junction without evidence of metastasis. Robot-assisted laparoscopic esophagogastric tumor excision, hiatal hernia repair and celiac lymph node excision was done with adequate margins without complication as presented in this video abstract. V151 Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement Neil D Patel, MD; Jessica Veatch, MD; CHI Health Creighton University Medical Center Bergan Mercy Percutaneous endoscopic gastrostomy (PEG) tube placement is a common gastrostomy tube placement technique. Although, widely used and generally successful, it is not always possible to obtain the conditions needed to avoid complications during placement, e.g. light reflex, 1:1 motion, safe tract method. Laparoscopic-assisted PEG tube placement offers a safe and effective alternative to laparoscopic/open gastrostomy tube placement or image-guided gastrostomy tube placement. Laparoscopic-assisted PEG tube allows for precise selection of the gastrostomy site and the opportunity to perform gastropexy under direct vision. The accompanying video demonstrates the technique in a patient in whom traditional PEG tube placement was not feasible. V152 Robotic Incisional Flank Hernia Repair with Mesh Stephanie Jensen, MD, MPH; Vedra Augenstein, MD, FACS; Atrium Health We present a case of a 79-year-old female with a history of spinal surgery who developed a symptomatic right lateral flank hernia at a previous incision site. She was taken for robotic flank hernia repair with mesh. An uncoated polypropylene midweight mesh was placed pre-peritoneally. She was discharged on post op day 0 and has had symptom resolution. This video highlights our surgical approach. V153 eTEP (Enhanced/Extended Totally Extra-Peritoneal) Inguinal Hernia Repair by Optical Entry Shubham Bhatia, MD 1; Aayushi Jain, MD2; Parveen Bhatia, MS, FRCS3; 1Flushing Hospital Medical Center, New York; 2Kern Medical Center, Bakersfield, California; 3Bhatia Global Hospital & Endosurgery Institute & Sir Ganga Ram Hospital, New Delhi, India We describe an optical entry approach to create the retrorectus and preperitoneal space under vision during eTEP (Enhanced Totally Extra Peritoneal) Inguinal hernia repair.eTEP is an extended or enhanced view modification technique based on the premise that the extraperitoneal space can be reached from almost anywhere in the anterior abdominal wall. The approach can quickly and easily create an extraperitoneal space, expand the surgical field, provide a flexible port setup, ease the management of the distal sac in cases of large inguinoscrotal hernias, and improve tolerance of pneumoperitoneum, which is a common complication of classic TEP technique. V154 Laparoscopic Transgastric Necrosectomy for WOPN German Rosero, MD; Sandra Pantoja, MD; Camilo Pachon, MD; Antonia Rosero, MS; Clinica de Marly We present the case of a female patient, 71 years old, with idiopathic severe pancreatitis. On day 20 of hospitalization, a percutaneous drainage of a pancreatic collection was done, obtaining 150 cc of purulent material positive for S.Constellatus. Later, she developed a pancreatic external fistula with 150 ml output/day. She persisted with sepsis, a MRI was done showing a WOPN and interrupted Wirsung duct at the middle portion, communicating with the collection. An intraoperative endoscopic ultrasound and laparoscopic transgastric drainage was done with resolution of the sepsis and the pancreatic fistula. She was discharged at 8th POP day. V156 Simultaneous Totally Extraperitoneal Repair of Bilateral Inguinal Hernias and Robotic Extended Totally Extraperitoneal Repair of Epigastric Ventral Hernia Joshua I Ng, MD 1; Desmond Huynh, MD1; Shirin Towfigh, MD2; 1Cedars Sinai Medical Center; 2Cedars Sinai Medical Center, Beverly Hills Hernia Center In this video we present a unique technique for simultaneous totally extraperitoneal (TEP) repair of inguinal hernias and robotic extended totally extraperitoneal (eTEP) repair of an epigastric hernia utilizing shared access to the retrorectus space through a single infraumbilical incision. The laparoscopic TEP was completed and then the retrorectus access for the eTEP repair was obtained by blunt superio-lateral dissection from the infraumbilical port rather than the conventional dissection from the left upper quadrant. We demonstrate that simultaneous TEP and eTEP utilizing the same infraumbilical retrorectus access is technically feasible for patients requiring both inguinal and ventral hernia repair. V157 Transatlantic Real-time Proctoring of Bilateral Retroperitoneoscopic Adrenalectomy in Lateral Decubitus Position Robert E Raskin, MD 1; Richard Spence, MD, MPH, PhD, FCSSA, FRCSC1; Jordan Eng, MD, FRCSC1; H. Jaap Bonjer, MD, PhD, FRCSC, FACS, FASCRS2; 1Dalhousie University; 2Amsterdam UMC This video abstract presents a case of retroperitoneoscopic bilateral adrenalectomy in lateral decubitus position by remote proctoring done by a surgeon who developed this technique. The video presents a case of a 39-year-old female who presented with bilateral pheochromocytoma. The case was performed in Halifax with real-time remote proctoring done by an expert surgeon in Amsterdam. The surgeon had never used the approach before, but after graded remote proctoring, including preoperative video coaching, the two surgeons felt comfortable to proceed. This video not only demonstrates the retroperitoneoscopic approach to adrenalectomy, but also highlights the opportunity presented by remote real-time proctoring. V158 Laparoscopic Ladd's Procedure in an Elderly Patient with Malrotation and Midgut Volvulus Benjamin A Palleiko, BS; Kevin M Dickson, BS; Sebastian K Chung, MD; John F Kelly, MD; John J Kelly; University of Massachusetts Chan Medical School Midgut malrotation is a congenital anomaly that can lead to volvulus. While most cases are diagnosed in infants, congenital malrotation can present symptomatically as midgut volvulus in adults. We present a rare case of malrotation and midgut volvulus in a 71-year-old female who presented with a small bowel obstruction with malrotation, as diagnosed on imaging and emergent diagnostic laparoscopy. A laparoscopic Ladd's procedure was performed, which the patient tolerated well before discharge on postoperative day three. We also performed a review of the literature of open versus laparoscopic Ladd's procedures. Laparoscopic Ladd's procedure is feasible and safe in adult patients. V159 Robot-Assisted Laparoscopic Repair of Right Sciatic Foramen Hernia and Bilateral Obturator Hernia John K Ewing, MD; Joseph M Blankush, MD; Joel F Bradley, MD; Joseph Broucek, MD; Vanderbilt University Medical Center A 71-year-old woman presented with right posterior leg pain. Physical exam demonstrated bilateral groin hernia. CT scan showed a right sciatic foramen hernia containing small bowel. A robot-assisted laparoscopic transabdominal pre-peritoneal repair was performed. Laparoscopy revealed bilateral obturator hernia in addition to the sciatic foramen hernia. On the right, pre-peritoneal dissection was carried posterolaterally to the sciatic foramen, and a single mesh was used to cover the myopectineal orifice, obturator foramen, and sciatic foramen. Left indirect and obturator hernia were repaired similarly. This video demonstrates minimally invasive repair of this rare combination of inguinal and pelvic floor hernia. V160 Giant Paraesophageal Hernia with Intrathoracic Spleen Devon Anderson, MD 1; Nalani Grace, MD, FACS2; James Wiedeman, MD, FACS2; 1University of California Davis Health; 2VA Northern California Health Care System This is a 63-year-old man with history of hypertension, hyperlipidemia, diabetes, and prior coronary bypass grafting who developed progressive dyspnea on exertion. Workup demonstrated a giant type IV paraesophageal hernia involving his stomach and spleen. He underwent a robot assisted paraesophageal hernia repair with partial (270) fundoplication and gastropexy after reduction of the intraabdominal contents from the left chest, which required splitting of the left crus. He did well postoperatively. Our video illustrates highlights from this unusual case. V162 Management of an Incidental Case of Para-Hiatal and Sliding Hiatal Hernia During Sleeve Gastrectomy Najla Al Ghaithi, MD, FRCSC; Hussam Al Amri, MD, FRCSC; Amin Andalib, MD, MSc, FACS, FRCSCFASMBS; McGill University Health Centre Para-Hiatal Hernia is a rare diagnosis and is difficult to diagnose preoperatively and can be confused with a paraesophageal hernia intra-operatively. Surgical techniques to repair para-hiatal hernias are not well established. In this video we present a management of an incidental case of Para-hiatal and sliding hiatal hernia during sleeve gastrectomy. We used non-absorbable sutures with pledges to close the defect and the patient had an excellent outcome. V163 Robotic-Assisted Laparoscopic Roux-En-Y Gastric Bypass Reversal Sydney Cooper, MD; Monique O Hassan, MD, MBA, FACS, FASMBS, DABOM; Baylor Scott and White Medical Center—Temple This video presents the case of a 57-year-old female who underwent elective robotic-assisted laparoscopic Roux-En-Y gastric bypass reversal due to chronic postoperative complications that she attributed to her surgery. Preoperative workup included upper endoscopy confirming resolution of a marginal ulcer and remnant gastrostomy placement for trial enteral feeding. The operation was performed by taking down and closing her feeding gastrostomy, resecting the Roux Limb, and creating a hand-sewn end-to-side gastrogastrostomy. Her postoperative course was complicated; however, she has had improved PO tolerance but remains on parental nutrition. V164 Laparoscopic Cholecystectomy of a Left Sided Gallbladder M Moughnyeh, MD; Y Zhang, MD; M Jacobs, MD; Ascension Providence/MSUCHM Left sided gallbladders are a rare anomaly of the biliary tract where the gallbladder is found to the left of the falciform ligament without situs inversus. In this video presentation, we present a left sided gallbladder found on entry into the abdomen and the subsequent dissection and completion of the cholecystectomy. We begin the dissection in a top down fashion and dissect out the critical view of safety before doing a completion IOC. V165 Key to Dissection of the Esophageal Hiatus Kristofer E Nava, MD; Amy Banks-Venegoni, MD; Spectrum Health Mastery of anatomy and identifying planes of dissection are paramount for maintaining safe surgical technique and ensuring high quality postoperative outcomes. With regards to foregut surgery, recognition of avascular planes allow for safe gastroesophageal junction mobilization. However, there is no standard approach for dissection of the esophageal hiatus. We present a standard approach to gastroesophageal junction mobilization in which a new plane of dissection, dubbed the Nava-Banks line, is identified. We propose this approach allows for a consistently safe dissection of the esophageal hiatus, which we predict will help in the prevention of post-operative GERD and hiatal hernia recurrence. V166 Robotic Transersus Abdominus Release for Large Incisional Hernias: 5 years of Experience at a Community Hospital Michael Dever, MD; Taylor Abraham, MD; Joseph Mayer, MD; Benjamin Biteman, MD, MS, FACS, FASMBS; St Joseph Warren Hospital Robotic assisted transversus abdominus release (rTAR) was introduced in 2012 as a modification of the Rives-Stoppa hernia repair technique. We present our experience at a single community hospital with a single surgeon with 51 patients operated on and followed from 2017 to 2022. Variables assessed were length of stay, recurrence rate and complication rate requiring readmission to the hospital. We present the video of a 55 year old female with a 9 cm wide defect who underwent rTAR. Total operative time was 158 min. She has suffered not complications from her repair and remains free of recurrence. V167 Pitfalls in Sleeve Gastrectomy: Retained Fundus Yannis Raftopoulos, MD, PhD, FACS, FASMBS; Shruthi Rajkumar, MBBS; Michael Bell, PAC; Elana Davidson, PAC, MPAS; Holyoke Medical Center In this video, we present a case series on incomplete gastric fundus resection after sleeve gastrectomy. An uneven sleeve caliber is a common cause of reflux after sleeve gastrectomy. We demonstrate our technique on how to manage this during the revision of sleeve gastrectomy and highlight the technical points that should be considered in the original sleeve gastrectomy to prevent this problem. This video focuses on the posterior dissection of the gastric sleeve wall for proper fundal resection. All the patients underwent a concomitant hiatal hernia repair. Other features of our sleeve gastrectomy are the no-bougie approach and the gastropexy. V168 Laparoscopic Management of Caudate Lobe Hydatid Cyst Vivek Kaje, MBBS, MS, DNB, SS, Surgical Gastroenterology; Yenepoya Medical College Hospital Hydatid disease of caudate lobe of liver presents technical challenge for the minimally invasive treatment. Here we present one such case of hydatid cyst of caudate lobe of liver with cystobiliary communication in a 29 years male who presented with abdominal pain & cholangitis. He was managed by pre operative ERCP with CBD clearance & CBD stenting followed by laparoscopic deroofing with omentopexy. V169 Robot-Assisted Laparoscopic Ligation of Gastroduodenal Artery Seth Petersen, MD; Alex Bonte, MD; Miles Dale, MD; Stephen Pereira, MD; Adam Rosenstock, MD; George Mazpule, MD; Hackensack University Medical Center We present a robot-assisted laparoscopic gastroduodenal artery ligation performed for upper GI bleeding from a duodenal ulcer, refractory to attempts at endoscopic and angiographic management. The patient is a 62-year-old female with nephrotic syndrome on chronic steroids. We elected to pursue a minimally invasive approach to suture ligation instead of the traditional laparotomy. While gastroduodenal artery ligation is performed robotically in elective cases, to the authors' knowledge, this is the first reported case of a robot-assisted laparoscopic approach being used to successfully address refractory bleeding from the gastroduodenal artery in an emergent setting. V170 Laparoscopic Partial Splenectomy for a Post-traumatic, Symptomatic Cyst in the Upper Pole of the Spleen Morgan Brazelle, MD; Daniel Farinas-Lugo, MD; Sebastian De La Fuente, MD; AdventHealth Orlando Introduction: The incidence of splenic cysts is notably low, and a non-parasitic splenic cyst is even more rare. These are classified as true and false cysts based on the respective presence or absence of an epithelial lining. Methods: This case demonstrates a posttraumatic symptomatic splenic cyst in an otherwise healthy female. She requested splenic preservation due to concerns of potential post splenectomy sepsis. Result: The patient recovered uneventfully and was discharged home 3 days after surgery. Pathology showed no evidence of malignancy. Conclusions: In selective cases, partial splenectomy is safe and can be done laparoscopically. V171 Attempted Laparoscopic Transcystic Common Bile Duct Exploration Michelle R McCullers, MD; Shawn E Moore, MD; Georg K Wiese, MD; AdventHealth Orlando A 34-year-old female with gallstone pancreatitis had normal bilirubin and ultrasound demonstrating cholelithiasis with a common bile duct (CBD) diameter of 5 mm. She underwent laparoscopic cholecystectomy with intraoperative cholangiogram, indicating a filling defect in the distal CBD refractory to saline flush and glucagon administration. A laparoscopic transcystic common bile duct exploration (LTCBDE) was performed, with retrieval of multiple stones and sludge. This was repeated several times with a residual filling defect. Thus, the decision was made to pursue postoperative endoscopic retrograde cholangiopancreatography (ERCP). In hindsight, alternative methods such as Fogarty catheterization or a transcholechochal approach may have been successful. V172 Combined Transoral Incisionless Fundoplication and Robotic Hiatal Hernia Repair—Case Series Steven M Elzein, MD; Daniel Tomey, MD; Maria Paula Corzo, MD; Rishabh Shah, MD; Rodolfo J Oviedo, MD, FACS, FASMBS; Houston Methodist Hospital Gastroesophageal reflux disease (GERD) has a prevalence of up to 28% in the U.S., making it one of the most common gastrointestinal disorders. While hiatal hernia repair and Nissen or Toupet fundoplication are considered standard of care, combined transoral incisionless fundoplication and hiatal hernia repair (cTIF) has recently been approved in patients with hiatal hernias > 2 cm and may reduce typical side effects of surgical fundoplication including gas bloating, excessive flatulence, and dysphagia. We highlight two side-by-side cases of cTIF and present the results of an eight-patient case series with follow-up ranging from two months to one year. V173 Laparoscopic Revision of Roux-en-Y Gastric Bypass to Sleeve Gastrectomy Mohammed Elshamy, MD; Alisa Khomutova, MD; Aurora Pryor, MD, MBA; Stony Brook University This is a case presentation of a 66-year-old female s/p remote Roux-en-Y gastric bypass, complicated by gastrojejunal marginal ulceration and stricture, which failed multiple endoscopic interventions. She elected for Roux-en-Y revision to sleeve gastrectomy to prevent weight regain. Intraoperatively, the roux limb measured 60 cm, this was stapled proximal to the jejeunojejunal anastomosis, and resected along with the gastrojejunal anastomosis, and fundus of the gastric remnant. A hand-sewn gastrogastric anastomosis was created between the pouch and gastric remnant. Finally, a sleeve gastrectomy was fashioned over an endoscope utilized as a bougie. She was discharged after tolerating diet and without complications. V174 Robotic-Assisted Splenic Flexure Resection David Ortega G Ortega, Research Fellow; Abhinav Gupta, Resident Physician Grad Year IV; Andrea Madiedo, Resident General Surgery; Sarah Koller, Assistant Professor Of Clinical Surgery; University of Southern California, Department of Colorectal Surgery Oncologic resection of the splenic flexure can be challenging. In this video, we show the key steps for robotic mobilization and resection of the splenic flexure. We also exhibit quick control of hemorrhage from the inferior mesenteric vein using a robotic vessel sealer. Lastly, we depict the utility of the robotic platform in creating an intracorporeal colonic anastomosis, which is particularly advantageous in a patient with a prior laparotomy incision and abdominal mesh, as it avoids any large incisions. As robotic surgery becomes more prevalent, we believe this video will serve as an invaluable reference for less experienced robotic surgeons. V175 Laparoscopic Removal of Gastric Band with a Flipped Port Extruding Through the Skin Adel Alhaj Saleh, MD, MRCS; Ryan Chin, MD; Ya Zhou, MD; Erin Moran-Atkin, MD; Jenny Choi, MD; Montefiore Medical Center A 55 y/o F with history of lap gastric band placement 12 years ago and abdominoplasty × 2 last one was a year ago. Presents with pain around the port site and open wound with visualization of the port. The port is seen extruding through the skin with minimal fibrin. Patient was taken to the operating room for laparoscopic removal of gastric band. No erosion of the band into the gastric lumen. Methylene blue test and UGI were negative for leak post op. Patient was discharged on POD#2. In conclusion: Port site infection/Extrusion through the skin is not always associated with band erosion into the gastric lumen. V177 Robotic Pelvic Exenteration Debra D Lai, DO 1; Laila Rashidi, MD2; Douglas Sutherland, MD2; 1Swedish Colon and Rectal Surgery; 2MultiCare This is a state of the art performance video relevant to colorectal surgery, urology, and robotics showcasing a robotic pelvic exenteration for rectal cancer. The patient is a 45 year old male with T4N1 rectal cancer status post total neoadjuvant therapy with mass at anal verge invading into sphincter and prostate. A combined case was performed by colorectal surgery, urology, and plastics for flap closure. The patient was able to discharge from the hospital on postoperative day two. V178 Laparoscopic Cystectomy for Foregut Duplication Cyst Chawisa Nampoolsuksan; Voraboot Taweerutchana; Siriraj Hospital, Mahidol University Foregut duplication cyst is a rare congenital disease. Patients can be asymptomatic or develop abdominal symptoms. Surgery is offered in symptomatic patient or malignant features. This video presented a 61-year-old female who had asymptomatic cyst with rapid growth during follow-up. Operation was scheduled for laparoscopic cystectomy. Intraoperatively, we found a 6-cm cyst mainly located at gastrohepatic region with partially adhered to the esophagogastric junction. Fully esophagogastric junction mobilization was done to facilitate dissection and Dor fundoplication was performed additionally. Pathology report revealed foregut duplication cyst without malignancy. After operation, patient was discharged home uneventfully. V179 Robot-Assisted Electrohydraulic Lithotripsy for Retained Common Bile Duct Stone Rui-Min D Mao, MD; Adrian Coleoglou Centeno, MD; Carlos Chavez, BS; Jennifer Moffett, MD, MS; University of Texas Medical Branch Electrohydraulic lithotripsy (EHL) utilizes electrical impulses to fragment objects; it can be used endoscopically to treat impacted common bile duct (CBD) stones. Its integration into robotic surgery remains limited, however we describe its successful use in a patient with a large, retained CBD stone following laparoscopic cholecystectomy. She underwent endoscopic retrograde cholangiopancreatography twice and robotic CBD exploration, all of which were unsuccessful. Repeat robotic CBD exploration with EHL fragmented the stone into smaller pieces, which were retrieved via basket. The patient was discharged home with a T-tube; this was pulled at 4 weeks, and she has been doing well since. V180 Cholecystectomy and Sigmoidectomy Using Robotic Natural Orifice IntraCorporeal Anastomosis with Transrectal Extraction (NICE Procedure) Horeb Cano Gonzalez, MD; Jose Lopez-Vera, MD; Mark Edgcomb, DO; Mike Liang, MD; HCA Houston Healthcare Kingwood The Robotic Natural-orifice Intra Corporeal anastomosis with trans-rectal Extraction (NICE procedure) has been reported before for diverticulitis. Laparoscopic cholecystectomy is considered as a gold standard for benign gallbladder diseases. The association of trans-rectal extraction for gallbladder and sigmoid has not been reported before. We present a case of 39 year old female with diverticulitis and chronic cholecystitis. Patient underwent Robotic assisted cholecystectomy and sigmoidectomy, both specimen were extracted through the rectum. Colorectal anastomosis was created intra-corporeal. The nice procedure can be used in a safe and reproducible fashion for combination of multi organ resection. V181 Remnant Cystic Duct Calculi After Robotic Cholecystectomy Ali Al Tuama, MB, BCh, BAO; Trieu Ton, DO; Alice Lee, DO; Aley Tohamy, MD; Crozer Chester Medical Center Background: 29 yr F with no past medical or surgical history presenting with a one day history of RUQ pain and found to have acute cholecystitis. Procedure: Robot assisted laparoscopic cholecystectomy. Complication: Development of abdominal pain six months after the procedure. Found to have a dilated cystic duct with cystic duct calculi. Management: Treated successfully with ERCP. Description: Video of robot assisted laparoscopic cholecystectomy displaying a dilated cystic duct. ICG used as well with satisfying images of biliary anatomy. Images from CT and MRCP to visualize the complication. V182 Laparoscopic Revision of a Partial Obstruction of the Roux Limb at the Mesocolic Window Following Roux-en-Y Gastric Bypass William C Hope, MD; Amelia Lucisano, MD, MS; Christopher Le, MD; Anita P Courcoulas, MD, FACS; Douglas A Reed, MD, FACS; Bestoun H Ahmed, MD, FACS, FASMBS, FRCS, ABOM; UPMC—Magee Women’s Hospital We present the technical details of the management of roux limb obstruction at the mesocolic window following retrocolic, retrograstric Roux-en-Y gastric bypass (RYGB). The patient underwent an uncomplicated retrocolic RYGB then presented 4 weeks later with low volume emesis and an upper gastrointestinal series showing partial obstruction at the mesocolic window. The patient underwent laparoscopic exploration. Narrowing secondary to dense scar tissue at the mesocolic window was confirmed. This was sharply dissected, freeing the roux limb, and relieving the obstruction. Intraoperative endoscopy was performed, and the endoscope passed easily through the area of prior obstruction. The patient recovered without complication. V183 Robotic Completion Gastrectomy and Construction of a Jejunostomy Tube Mayte Bryce-Alberti, MD1; James Connolly, MD2; Cheguevara Afaneh, MD, FACS, FASMBS2; Omar Bellorin-Marin, MD, FACS, FASMBS 2; 1Universidad Peruana Cayetano Heredia; 2NewYork-Presbyterian / Weill Cornell Medicine The following video depicts the robotic completion gastrectomy and construction of a jejunostomy tube in a 28 year-old female with a history of severe gastroparesis. She complained of abdominal pain, nausea and vomiting with solids and liquids even after undergoing a PEG-J tube placement in March 2021. On November 2021 she had a gastric bypass surgery with feeding tube gastrostomy, but was still unable to tolerate oral intake. Thus, in March 2022 she underwent surgery, after which she was soon discharged without complications and with improvement of the nausea and abdominal pain. V184 Robotic Transabdominal Drainage of Epidiaphragmatic Abscess Indraneil Mukherjee 1; Harpreet Kaur2; Adeel Shamim3; Rayna Walburger4; Nisha Narula1; Karen E Gibbs5; Lisa Shimotake1; 1Staten Island University Hospital—Northwell Health; 2Bronx Care Hospital System; 3Mercy Hospital, Fort Smith; 4Mount Sinai Hospital; 5Yale University—Bridgeport A 32-year-old male presented with right shoulder pain. On imaging, he was stated to have a large subdiaphragmatic abscess. 3 months previously he had a similar abscess that was treated with Aspiration and Antibiotics. He had a Past medical of Crohn’s ileitis for over 10 years, which had not been treated with any medications. He had a recent history of liver abscesses and empyema 3 years ago, which were treated with antibiotics and multiple drains. He was taken to the operating room where he underwent a robotic-assisted drainage of abscess which intraoperatively was found to be above the diaphragm. V185 Laparoscopic Management of Post Cholecystectomy Syndrome from Cystic Duct Calculi Alexander Ostapenko, MD; Jennifer Liu-Burdowski, MD; Ramanathan Seshadri, MD; Danbury Hospital Post cholecystectomy syndrome (PCS) constitutes a constellation of symptoms mimicking biliary pathology after a cholecystectomy. One of the causes of PCS is from retained calculi in the common bile duct or cystic duct stump. We present a case of a 47-year old female with retained stones in the cystic duct remnant 8 years after a laparoscopic cholecystectomy. In this video we perform a laparoscopic cystic duct stump excision with intraoperative cholangiogram. We demonstrate that post-cholecystectomy syndrome from cystic duct calculi can be successfully managed in a minimally invasive fashion. V186 Concomitant Transoral Incisionless Fundoplication (cTIF)—Synergy Between Laparoscopy and Endoscopy Kevin L Wissinger, MD; James J Reeves, MD; Bryan J Sandler, MD; Garth R Jacobsen, MD; Ryan C Broderick, MD; Santiago Horgan, MD; University of California San Diego We present a concomitant transoral incisionless fundoplication (cTIF). This procedure entails endoscopic fundoplication to create the gastroesophageal flap valve intra-luminally, with laparoscopic hiatal hernia repair. The patient presented with classic esophageal and upper airway related symptoms of reflux and our pre-operative evaluation for hiatus hernia and reflux is highlighted. The workup follows SAGES guidelines, and we discuss the various approaches to anti-reflux surgery. The hiatal hernia dissection and crura closure are broken down in a step-by-step manner to demonstrate the anatomy and anti-reflux mechanisms, and the gastroesophageal flap valve is emphasized following the endoscopic fundoplication. V187 Laparoscopic Management of Complete Gastric Band Obstruction 17 Years After Placement Susan K Campbell, MD; Berna F Buyukozturk, MD; Wasef Abu-Jaish, MD; University of Vermont Medical Center A 61 y.o. female with remote history of laparoscopic gastric band placement, and subsequent 200-pound weight loss, presented with five days of nausea, vomiting, and anorexia. Following band fluid removal, abdominal CT scan and upper GI examination showed complete band obstruction. Our video demonstrates safe laparoscopic removal of a gastric band with dense adhesions. Intra-operative endoscopic evaluation should be performed to ensure resolution of the obstruction and to perform an air leak test. Her post-operative course was uneventful, and at her follow up appointment four weeks later she was tolerating a regular diet and gaining an appropriate amount of weight. V188 Robotic-Assisted Bilateral Inguinal Mesh Explantation Yuhamy Curbelo-Pena, MD; Amy Holstrom, MD; Gregory Dakin, MD, FACS; Cheguevara Afaneh, MD, FACS; Omar Bellorin-Marin, MD, FACS; New York Presbyterian Hospital This video reports the usefulness of the robotic approach during bilateral inguinal mesh explantation. A 28-year-old male, former bodybuilder with history of bilateral inguinal hernia repair with mesh in 2018, came to our office complaining of 4 months of severe bilateral groin pain and constipation. An important area of bilateral inguinal inflammation was noted on the Ct scan. A bilateral inguinal exploration found a bilateral folded mesh with intense fibrosis affecting the sigmoid colon. Bilateral mesh explanation and reconstruction with biosynthetic mesh were successfully achieved. This approach appears safe and valuable during inguinal mesh explantation, an anatomically complex area. V189 Laparoscopic Splenic Abscess Drainage and Debridement Adam Gendy, MD; Olivia Haney, MD; Taylor Loui, MD; Indraneil Mukherjee, MD; Staten Island University Hospital We present a case of a 74-year-old male with a non-contributory past medical history that came to the hospital with a three-week complaint of left upper abdominal pain as well as subjective fevers, chills, and sweats. His physical exam was significant for being febrile and tender to palpation in the left upper quadrant. A CT-scan showed that he had a large splenic abscess that was subsequently treated with intravenous antibiotics and percutaneous drainage. His abscess did not resolve, and he was eventually taken to the operating room for a laparoscopic splenic abscess drainage and debridement using Indocyanine green (ICG). V190 Robotic-Assisted Approach of Epiphrenic Esophageal Diverticulum, Hiatal Hernia and Morbid Obesity Alvaro Ducas, MD; Lorna Evans, MD; Rocio Castillo Larios, MD; Michel Cordies, MD; Fernando Elli, MD, FACS; Mayo Clinic Surgical treatment of patients with morbid obesity, hiatal hernia associated with esophageal dysmotility with epiphrenic diverticulum is difficult due to the number of procedures that must be performed in the same patient. We present a 74-year-old patient, BMI 41, with an epiphrenic esophageal diverticulum associated with esophageal dysmotility with symptoms of digestive intolerance, nocturnal vomiting and pneumonia. It was decided to perform robotic-assisted esophageal diverticulectomy, Heller myotomy, hiatal hernia repair and Roux-en-Y gastric bypass. On the first postoperative day, an esophagram was performed which showed no fistulas and good passage of contrast through the anastomosis. V191 ROBOT-ASSISTED Laparoscopic Ileal Conduit Resection, Revision and Recreation: Ileal Conduit Resection for Ureteroenteric Fistula with Creation of New Ileal Conduit Tamar Sherman, DO; Mutahar Ahmed, MD; George Mazpule, MD, FACS; Hackensack University Medical Center We present a robot-assisted laparoscopic small bowel resection and creation of small bowel pedicle for ileal conduit formation secondary to a ureteroenteric fistula and stricture of the ileal conduit. The patient is an 82 year old male with a history of bladder cancer treated with neoadjuvant therapy followed by surgically treatment with robot-assisted radical cystoprostatectomy and ileal conduit creation. To the authors' knowledge, this is the first reported case of an ureteroenteric fistula to an ileal conduit performed and repaired robotically. V192 Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery (SMA) Syndrome with Duodenal Obstruction Aditya Kumar; Subashree S; Nikhil Gupta; Arun K Gupta; ABVIMS & Dr RML Hospital Superior mesenteric artery syndrome is a rare cause of bowel obstruction in up to 0.3% cases. An aorto-mesenteric angle of less than 25° leads to compression of the duodenum. Conservative management with naso-jejunal feeding is usually attempted and surgery reserved when it fails. Open duodeno-jejunostomy, Strong's procedure and gastrojejunostomy are options available and used most often. Laparoscopic duodeno-jejunostomy can offer a safe and feasible option with the inherent advantages of minimal access techniques over open surgery. Key steps of the procedure have been described in this video on a 16-year-old girl who presented with recurrent bilious-vomiting and significant weight-loss. V193 Video Assisted Thoracoscopic Surgery (VATS) for the Resection of an Anterior Mediastinal Mass Muhammad Hanif, Professor, Dr; Rabia Arshad, Dr; Daneyal Arshad, Dr; Zeeshan Azam, Dr; Ruqia Mushtaq, Dr; Rawalpindi Medical University, Rawalpindi, Pakistan This video demonstrates 'Video Assisted Thoracoscopic Surgery (VATS)' for the resection of an anterior mediastinal mass in a 55-year-old female. The patient presented with complaints of difficulty in swallowing, fatigue, doubling of vision, and weakness of peripheral muscles. She was diagnosed as a patient of 'Myasthenia Gravis'. Contrast Enhanced CT Chest showed a lobulated matted confluent tissue mass with dense calcification in the anterior mediastinum, more towards the left of mid-line. Histopathology of the mass revealed a Type B2 Thymoma, measuring 7.0 × 5.0 × 1.5 cm, with the involvement of the Phrenic Nerve. Pathological stage was pT3 & pNX. No lymphovascular invasion was observed. V194 Direct Adenoma Robotic Excision (DARE) Sendy Ha, MD; Daniel Ojala, DO; Eben Strobos, MD, FASCRS, FACS; St. Anthony Hospital Adenomatous polyps of the colon should be resected due to their malignant potential. Polypectomies can be performed endoscopically or surgically. Direct Adenoma Robotic Excision (DARE) is a colonoscopy-assisted robotic polypectomy with the Da Vinci system and the TilePro feature, which allows for a picture-in-picture simultaneous robotic-colonoscopic procedure. In select patients with low risk adenomatous polyps and benign biopsies without dysplasia, this surgical approach may be an alternative to an oncologic colectomy, particularly in patients with significant comorbidities who may not tolerate such a procedure or those in whom a colectomy would pose significantly decreased quality of life. V195 Robotic Transabdominal Extraperitoneal Lumbar Hernia Repair with Fibrin Glue Fixation of Prosthetic Mesh Hunter Belanger, DO; Dominique Dempah; LewisGale Salem The video displays the surgical technique used for a robotic transabdominal extraperitoneal repair of a lumbar hernia with mesh fixation using fibrin glue in a 61-year-old female. Shown is creation of a preperitoneal flap located medial to the white line of Toldt to give access to the retroperitoneal space. After which, the lumbar hernia is identified, reduced, and closed with a 1–0 Stratafix. Next, a large mesh is placed within the preperitoneal flap and secured with fibrin glue. Finally, the preperitoneal flap is reapproximated with a 2-0 Stratafix. Pre and 2 year post CT images are included. V196 Classic Duodenal Switch Robotic Revision with Elongation of the Common Channel to Increase Absorption Roberto Secchi del Rio, MD 1; Daniel Tomey, MD2; Victor G. Peña, MD3; Maria Paula Corzo, MD4; Victor Bolívar, MD5; Suman Shetty, MSII6; Osagwu Nnenna, MS7; Rodolfo J. Oviedo, MD, FACS, FASMBS, FICS8; 1Universidad Anahuac Queretaro, Mexico, School of Mexico; 2The University of Zulia, Faculty of Medicine. Maracaibo, Venezuela; 3Universidad de Monterrey, Mexico, School of Medicine; 4Universidad de Los Andes,School of Medicine, Bogotá, Colombia; 5Universidad de Oriente, Faculty of Medicine, Venezuela; 6University of Texas at Austin; 7All Saints University,School of Medicine, Roseau, Dominica; 8Houston Methodist Academic Institute Classic duodenal switch produces a significant weight loss in bariatric patients, but it does not come without its risks. It is a complex surgery that involves malabsorption and can lead to severe chronic malnutrition and vitamin deficiencies. We present a case of a 70-year-old male with chronic malnutrition and vitamin deficiencies secondary to laparoscopic duodenal switch surgery. To regain the absorptive function, we elongated the common channel and alimentary limb with a robotic revisional approach, increasing the absorptive surface and improving the nutritional status. There were no operative complications, and 1-year follow-up showed improved GI function with no complications. V197 Duodeno-Jejunal Bypass for SMA Syndrome Alisa Khomutova, MD; Mohammed Elshamy, MD; Aurora Pryor, MD; Stony Brook University A 38 year old female with history of SMA syndrome presented with gradual worsening of post-prandial nausea and development of NBNB vomiting. A CTA showed the duodenum to be dilated and the angle between the SMA the aorta was decreased (15 degrees). A Gastric Emptying Study showed mildly delayed gastric emptying and an upper GI swallow study showed normal passage of barium from the duodenum into the proximal jejunum. Finally, a diagnostic NJ tube placement showed improvement of nausea with delivery of tube feeds past the mechanical obstruction. We performed a laparoscopic duodenojejunostomy and her symptoms resolved. V198 Laparoscopic Lysis of Adhesions and Graham Patch Repair of Perforated Marginal Ulcer Emily Ortega Goddard, MD; Marcoandrea Giorgi, MD; The Warren Alpert Medical School of Brown University, The Miriam Hospital, Providence, RI This is a 71 yo M with a past surgical history of open RNYGB and open ventral hernia repair with mesh, and past medical history of adrenal insufficiency on steroids and an everyday cigar smoker. He presented to the emergency department with localized peritonitis from marginal ulcer perforation. During laparoscopic exploration, extensive adhesiolysis was performed. A laparoscopic graham patch repair and leak test was initially performed, but was positive for a leak. The patch was reinforced and repeat endoscopy was negative for a leak. Postoperatively, the patient had no leak on UGI and was discharged on a clear diet. V199 Robot Assisted Laparoscopic Repair of 8 mm Trocar Colonic Injury Nicole Hadjiloucas; Miles Dale; Adam Rosenstock; Hackensack University Medical Center This video depicts a trocar injury to the colon with the robotic trocar. The repair for this injury took into account the damage to the colon, the most optimal type of repair, and patient safety. This injury, while unfortunate, provided an opportunity to educate others on how to repair this type of injury. While colonic injuries from a trocar are rare, the repair can be safely achieved robotically. V200 Robotic Central Pancreatectomy for Neuroendocrine Tumor Sara A Alkhaja, MD; Yasir Akmal, MD; Mohammed Abdallah, MD; Essa M Aleassa, MD; Cleveland Clinic Abu Dhabi Introduction: Central pancreatectomy has been primarily performed using an open approach with very limited use of minimally invasive techniques due to its complexity. Methods: Case of a 68-year-old female with pancreatic neuroendocrine tumor who underwent a robotic central pancreatectomy. Results: Robotic dissection performed to expose the pancreas. Laparoscopic ultrasound used to localize the lesion in pancreatic neck. Proximal pancreas transected with stapler and distal margin divided with monopolar. A posterior gastrotomy made and pancreatogastrostomy fashioned. Patient discharged on post-operative day 7. Pathology showed moderately differentiated neuroendocrine tumor. Conclusion: Robotic central pancreatectomy is feasible and offers benefits of minimally invasive approach. V201 Bougie Perforation During Routine RYGB… and How We Fixed It! Melissa N Hanson, MD; Phil Vourtzoumis, MD; Sebastian Demyttenaere, MD, MSc; Amin Andalib, MDCM, MSc; Olivier Court, MD; McGill University The patient is a 51-year-old male (BMI of 39.8 and a history of hypertension, dyslipidemia, no prior abdominal surgeries) planned for a routine RYGB. During creation of the pouch, a perforation in the posterior gastric wall was identified secondary to the 60 FR bougie dilator. Three proposed factors that contributed to this complication: the pouch was a bit long, posterior adhesions/insufficient dissection, and most importantly inadequate communication. The injury was repaired, and the patient did not have any post-operative complications. At his 1-month follow-up visit he was doing well, and his BMI was 34.8 (12.6% total weight loss). V204 Robotic Repair of Flank Hernia and Diaphragm Rupture Leah Conant, MD; Jeffrey Blatnik, MD; Washington University in St. Louis The submitted video describes a complex repair of a right flank hernia and diaphragm rupture. This was done robotically. The initial attempt at access to the abdomen resulted in trocar placement into the right pleural space given the downward displacement of the diaphragm due to herniation. During the primary repair of the defect, a contoured shaped defect was noted. As such, a contoured mesh, typically used for inguinal hernia repair, was utilized to reinforce the hernia repair. V205 Robotic Assisted Repair of Grynfeltt-Lesshaft Lumbar Hernia Alexander Kersey, MD 1; Gao L Chen, MD, FACS2; 1Walter Reed National Military Medical Center; 2Mid-Atlantic Permanente Medical Group This video is a description of a robotic trans-abdominal pre-peritoneal approach for repair of a superior triangle (Grynfeltt-Lesshaft) lumbar hernia. It covers the preoperative evaluation, key anatomical landmarks, and operative steps utilized when approaching this repair. This case utilizes the use of a self-gripping mesh in the pre-peritoneal plane to avoid injury to nearby nerves and exclusion of the mesh from the abdominal cavity by closure of the peritoneal flap over the mesh. V206 Robotic Blumgart Anastomosis: A Familiar Pancreaticojejunostomy Jonathan C DeLong, MD; Rachel M Jensen, MD; Rejoice F Ngongoni, MD; Hester C Timmerhuis, MD; Cintia Kimura, MD; David I Hindin, MD; Brooke Gurland, MD; Monica M Dua, MD; Brendan C Visser, MD; Stanford The Blumgart-style pancreaticojejunostomy is a technique popularized by L.H. Blumgart in which a duct-to-mucosa anastomosis is sewn and the cut edge of the pancreas is invaginated into the proximal jejunum. The technique has been shown to decrease the incidence of post-operative pancreatic fistulae. In this video, we demonstrate how this technique can safely and practically be performed using the robotic surgery platform in essentially the same manner as it's open counterpart. We will go step-by-step with detailed instruction for each maneuver. V207 Single Anastamosis Duodeno-Ileal Bypass After Failed Sleeve Gastrectomy Shubham Bhatia, MD 1; Aayushi Jain, MD2; Parveen Bhatia, MS, FRCS3; 1Flushing Hospital Medical Center, New York; 2Kern Medical Center, Bakersfield, CA; 3Bhatia Global Hospital & Endosurgery Institute & Sir Ganga Ram Hospital, New Delhi, India The need for revisional procedures after Sleeve Gastrectomy for weight regain, reflux, or other complications is around 18–36%. Conversion into a SADI results in significantly more weight loss while complications and nutritional deficiencies were similar and may be considered the recommended operation when additional weight loss is goal, as in our patient. SADI is a simplification of duodenal switch (DS) and has lower risk of malabsorption, while weight loss and comorbidities resolution are comparable. The preservation of pylorus is thought to reduce rate of anastomotic ulcer and decrease hypoglycemic episodes, dumping and hence provide better quality of life. V208 ROBOTIC-ASSISTED Roux-en-Y Gastric Bypass Conversion and Hiatal Hernia Repair Lorna A Evans, MD; Alvaro Ducas, MD; Rocio Castillo-Larios; Michel Cordies; Enrique F Elli, MD, FACS; Mayo Clinic We present a 67-year-old patient with a BMI of 47 with a previous Medical History of laparoscopic Nissen fundoplication times 2. One of the procedures was performed in the 1990s and the second one was performed in 1996. Both procedures were done at another institution. Furthermore, the patient has a known esophageal stricture which was dilated in May 2021 to 17 mm. Said patient, intercurred in 2021 with reflux, heartburn, regurgitation, occasional dysphagia and choking sensation. V209 Small Bowel Obstruction Secondary to Foramen of Winslow Hernia: A Video Presentation Ali Safar; Sebastian Demyttenaere; McGill University Foramen of Winslow Hernia is an extremely rare entity, accounting for up to 0.08% of all hernias. It is often an overlooked diagnosis with a high mortality rate. We present an interesting case of small bowel obstruction secondary to foramen of Winslow hernia in a 39 year old gentleman who is otherwise healthy. Imaging revealed an abnormally located small bowel loops adjacent to the lesser sac of the stomach. He underwent diagnostic laparoscopy with successful reduction of the herniated small bowel loops and primary closure of the defect. His postoperative course was uneventful. V210 Laparoscopic TAPP Repair of Left Sided Primary Lumbar Hernia Shazia Khan, Ms; Lamis Abdelkarim, Ms; Princess Alexandra Hospital NHS trust Introduction: Lumbar hernias are defined as protrusion through defect in the posterior abdominal wall. Primary lumbar hernias are very rare. Methods: The patient was 44 year old male presenting with intermittent pain and lump in left lumbar region for 2 years. Clinical examination and CT scan was suggestive of Left lumbar hernia. We have demonstrated laparoscopic repair with primary suturing of defect and insertion of prosthetic mesh. Results: There were no intra operative or post operative complication or recurrence of hernia. Conclusion: High index of suspicion is required to diagnose primary lumbar hernia. Laparoscopic technique is feasible and is gaining popularity. V211 Laparoscopic Transgastric Resection of a Submucosal Gastroesophageal Junction Leiomyoma Olivia Haney, MD 1; Abdullah Khalil, PA Student2; Indraneil Mukherjee, MBBS, MD1; 1SIUH; 2SUNY Downstate A 49 yo male was found to have a small submucosal gastroesophageal junction tumor (likely leiomyoma by biopsy). A laparoscopic transgastric approach was used, in combination with endoscopy, to resect the submucosal mass from within the lumen of the stomach, saving him from potentially having a more invasive partial gastrectomy due to the mass' location. A minimally invasive transgastric approach is beneficial both in locating and excising intraluminal gastric masses, while also decreasing the patient's morbidity and length of stay. V212 Robotic Intersphincteric Resection with En Bloc Prostatectomy for T4b Rectal Cancer Min Hye Jeong1; Hye Jin Kim 1; Jun Seok Park1; Soo Yeun Park1; Seung Ho Song1; Yun-Sok Ha2; Sung Min Lee1; Dong Hee Na1; 1Colorectal Cancer Center, Kyungpook National University Chilgok Hospital; 2Department of Urology, School of Medicine, Kyungpook National University We aimed to describe the surgical technique of robotic ISR with en bloc prostatectomy. A 57-year-old male had a T4b rectal cancer at anal verge 4 cm invading the prostate. He received preoperative CCRT and still the cancer was suspected to T4b. We did a robotic ISR with en bloc prostatectomy. A coloanal anastomosis and a protective stoma were made. There was no perioperative complication. The pathology revealed ypT4bN1a. Robotic ISR with en bloc prostatectomy is a safe option in the treatment of T4b rectal cancer. V213 Robotic Transanal Minimally Invasive Repair of Colorectal Anastomotic Leak Katherine E Barnes; Fernanda Romero-Hernandez, MD; Hueylan Chern, MD; Ankit Sarin, MD, MHA; University of San Francisco, CA We present a 57-year-old male who underwent robotic-assisted laparoscopic anterior resection for advanced rectal cancer. Postoperative course was complicated by anastomotic leak, which required drain placement and diverting loop ileostomy. Due to persistent pain at the drain site and to expedite healing, it was decided to perform robotic transanal repair. After identifying the anastomosis, the abscess cavity was debrided and irrigated. The defect was repaired using running V-locking 2–0 PDS. The patient had no postoperative complications. A small rectal fistula was seen at 6-week follow-up due to the size of the disruption; this resolved by week 8 without further intervention. V214 A Video Case Presentation of Pericardio-diaphragmatic Rupture (PDR) Eliah Lux, BA 1; Maria Chulkov, MD2; Mohamed Al Yafi, MD3; Jianlin Tang, MD, FACS4; Aela Vely, MD4; 1University of Toledo College of Medicine and Life Sciences; 2University at Buffalo Pediatric Surgery Program; 3University of Toledo General Surgery Residency Program; 4Department of Surgery, University of Toledo College of Medicine and Life Sciences Pericardio-diaphragmatic rupture (PDR) is an injury of rare occurrence. We present a video-recorded case of PDR in a 70 year old man involved in an MVC. His injury was identified during a diagnostic laparoscopy and subsequently repaired. A lit review showed 110 case reports of PDR since 1910, only five of which were repaired laparoscopically. Given the demonstrated benefits of this approach over open surgery in other surgical settings, utilization of laparoscopy in treating PDR warrants documentation and further study. V215 Robotic Incisional Hernia Repair with Bilateral Anterior Component Separation Vikrom K Dhar, MD; Omar Bellorin, MD; Gregory Dakin, MD; Cheguevara Afaneh, MD; New York Presbyterian Hospital—Weill Cornell Medical Center In this video, we present a 66 year old gentleman with history of multiple prior abdominal surgeries now with a symptomatic midline incisional hernia. On physical exam, he was noted to have an 8 × 8 cm reducible incisional hernia and was recommended to undergo robotic incisional hernia repair. Here, we discuss the relevant anatomy and operative techniques for performing bilateral anterior component separation with a robotic approach. V216 Obstruction of the Gastric Outflow Tract by Gallstones (Bouveret Sydrome). A Minimally Invasive Surgical Approach to the Duodenum Felipe Victer, MD, FACS; Giovanna Areco, MD; Cesar Amorim, MD; Andre Ricardo C dos Santos, MD; HUCFF An 89-year-old patient seeks an emergency with abdominal pain and a duodenal obstruction due to a gallbladder calculus. In addition, the patient had pleural neoplasia under investigation and pulmonary thromboembolism with anticoagulant use. Obstruction of the gastric outflow tract may also be called Bouveret syndrome. The patient was approached in a minimally invasive way with the removal of the stone in the 3rd duodenal portion. Despite the good clinical evolution, she had a low-output fistula, which was also successfully managed in a minimally invasive way with the help of flex endoscopy and the use of intraluminal vacuum. V217 ICG During Splenectomy: The Pancreas and The Splenule Domenech Asbun, MD; Horacio J Asbun, MD; Miami Cancer Institute During minimally invasive splenectomy, surgeons intend to avoid injury to the tail of the pancreas. Such injury may lead to troublesome postoperative morbidity. We present the video of a laparoscopic splenectomy for immune thrombocytopenia in which the tail of the pancreas was immediately adjacent to the splenic hilum. It was surrounded by adipose tissue and difficult to distinguish from surrounding structures. Using indocyanine green fluorescent imaging, the edges of the pancreas are clearly identified and pancreatic injury is avoided. Furthermore, a splenule was identified, which was important to include in the resection. The patient did well postoperatively with no complications. V218 Robotic Ventral Mesh Rectopexy: Comparing Patient Features and Surgeon Techniques Cintia Kimura, MD, PhD1; Craig Olson, MD 2; Caitlin Bungo, BS1; Jonathan DeLong, MD1; David Hindin1; Brooke Gurland, MD1; 1Stanford University; 2University of Texas Southwestern Medical Center Ventral Mesh Rectopexy is a procedure option for patients with rectal prolapse. Surgical techniques vary, as do patient features. This video demonstrates two different patients undergoing robotic VMR by two different surgeons in the United States. The following steps are demonstrated: 1. exposure of the pelvis and anatomy identification; 2. identification of the proximal fixation point; 3. rectovaginal dissection; 4. fixation of the mesh to the sacrum; 5. closure of the peritoneum. In the video, we highlight and discuss differences in patients' characteristics, and surgeons' techniques. V219 ICG Perfusion Assessment in Laparoscopic Sleeve Gastrectomy, Should It be Routine? Ana Carrasquilla, MD1; Nia Zalamea, MD 2; Jorge Esmeral, MD1; 1Hospital CIMA San José; 2University of Tenessee Health Science Center Gastric leak is the most fear complication in bariatric surgery, ischemia is one of the factors in its pathophysiology. This is a female patient, 41 years old, BMI of 30.1 kg/m2. After the sleeve is created with a 36Fr bougie the anesthesiologist injected 2.5 mg ICG IV. The view of laparoscope is changed to NIR light, the sleeve is evaluated with fluorescent angiography with green and black and white mode. The use of ICG angiography gives real-time assessment of tissue perfusion, intraoperative findings can lead to revision or reinforcement. V221 Laparoscopic Standardized Paraesophageal Hernia Repair and Partial Fundoplication Andres Latorre-Rodriguez, MD; Sumeet K Mittal, MD; Norton Thoracic Institute, St Joseph's Hospital and Medical Center We present a step-by-step technique of large paraesophageal hernia (PEH) repair with partial fundoplication. Steps for PEH repair highlight sac excision, mediastinal mobilization, and crus closure. A standardized and reproducible fundoplication technique is described, including separation of vagus nerves from the esophagus and Angle of His accentuation (A.O.H fundoplasty). This systematic technique includes extensive dissection, reduction, and mobilization of the hernia sac and partial fundoplication (Toupet). Endoscopic pictures after each step of the fundoplication are included. V222 Ladd's Bands and Atypical Malrotation as a Cause of Chronic Abdominal Pain in an Adult: A Case Report and Video Vignette Lucas Fair, MD; Brittany Buckmaster, PAC; Steven Leeds; Baylor University Medical Center Intestinal malrotation consists of a spectrum of abnormalities of intestinal positioning and fixation, ranging from normal positioning to typical malrotation to all kinds of variations in between. Several names have been given to these variations, including "atypical". Patients with intestinal malrotation can remain asymptomatic and therefore remain undiagnosed. In symptomatic cases, patients usually present with either acute or chronic abdominal pain. The chronic presentation is more common in adults, and usually presents as nonspecific abdominal pain. We present a case of Ladd's bands and atypical malrotation as a cause of chronic abdominal pain in an adult. V223 Smart Glasses for Training Program: Transatlantic PERCUTANEOUS Surgery Guidance in a Fellowship Program Ana Karla Uribe Rivera, MD 1; Eduardo Houghton, MD, PhD1; Mariano E. Giménez, MD, PhD2; 1Daicim Foundation, Training, Research, and Clinical Activity in Minimally Invasive Surgery, Buenos Aires, Argentina; 2President of Daicim Foundation, Training, Research, and Clinical activity in Minimally Invasive Surgery, Buenos Aires, Argentina. Professor of Surgery "Taquini" Chair of General and Minimally Invasive Surgery—University of Buenos Aires, Argentina. Chair of Excellence in Percutaneous Surgery at Institute for Advanced Studies—University of Strasbourg, France. Scientific Director of Percutaneous Surgery—IHU-IRCAD. Strasbourg, France Background: Technology helps to improve the techniques used by the guidance of expert staff in a fellowship program, which it's crucial for learning complex procedure techniques such as biliary endocanalicular radiofrequency. Materials and Methods: We used smart glasses, an endoHPB radiofrequency device, a connection through the computer, and mobile devices for telementoring between the trainer and the trainee. Results: Smart glasses seem to play a vital role in onsite education and research activities. Conclusions: The smart glasses prove potential contributions to this surgical indication, allow telemonitoring, and the trainer with the trainee can be in different places working together. V224 Laparoscopic Assisted Left Adrenalectomy for a Giant Adrenal Myelolipoma Shubham Bhatia, MD 1; Aayushi Jain, MD2; Parveen Bhatia, MS, FRCS3; 1Flushing Hospital Medical Center, New York; 2Kern Medical Center, Bakersfield, California; 3Bhatia Global Hospital & Endosurgery Institute & Sir Ganga Ram Hospital, New Delhi, India Adrenal myelolipoma (AML) is a rare tumour composed of fat and myeloid tissues. It is defined as "giant myelolipoma" if size exceeds 10 cm. Indications of surgery include: symptomatic, hormonally active, or large size. The risk of malignancy increases to 25% in lesions > 6 cm. Small, non-functioning tumors are followed radiologically annually. Giant myelolipomas (> 10 cm) are more commonly associated with intraoperative complications, like bleeding, capsular breach and local recurrence. Most are excised via open approach, and very scarce evidence can be found regarding Laparoscopic approach. We present a case to demonstrate Laparoscopic approach is safe and feasible. V225 Single-Handed Single-Instrument Intracorporeal Suturing in Single Incision Laparoscopic Cholecystectomy Shubham Bhatia, MD 1; Aayushi Jain, MD2; Parveen Bhatia, MS, FRCS3; 1Flushing Hospital Medical Center, New York; 2Kern Medical Center, Bakersfield, California; 3Bhatia Global Hospital & Endosurgery Institute & Sir Ganga Ram Hospital, New Delhi, India During laparoscopic cholecystectomy in situation of a wide cystic duct, the 'clip will slip', and suturing provides a safe option. The added safety of suture ligation in cases of wide cystic duct can also be offered in single-incision laparoscopic cholecystectomy. This can be achieved by inserting a transfixation suture Vicryl No. 1 using 12 mm port and pulling tail out of 5 mm port. The key to the maneuver is roticulating movements of the instrument with supination and pronation of the wrist to perform single-handed single-instrument suturing without compromising safety. V226 Laparoscopic Paraesophageal Hernia Repair: An Educational Video Hillary Wilson1; Breanna Fang1; Alexandra Chow1; Jerry Dang 2; Shahzeer Karmali1; 1University of Alberta; 2Cleveland Clinic The objective of this video was to provide an educational tool for surgical trainees to learn the operational steps of a laparoscopic paraesophageal hernia repair. This procedure is a critical component in the management of gastroesophageal reflux disease and Barrett's esophagus. However, surgical volume of this procedure is variable across residency programs. Alternative methods are needed for surgical trainees to learn about procedures including the laparoscopic paraesophageal hernia repair. We present an educational video of a laparoscopic paraesophageal hernia repair performed by an experienced, fellowship-trained minimally invasive surgeon. Narration of each step is included to optimize the learning experience. V227 Minimizing Maternal–Fetal Radiation, Why ERCP When You Can IOC? Matthew J Billy, DO; Tristan T Seton, MD; Alexandra M Falvo, MD, FACS; Ryan D Horsley, DO, FACOS, FASMBS; Geisinger (SSO) We present a case of a 31-year-old female at 17 weeks gestation by last menstrual period who presents to the hospital with recurrent gallbladder symptoms concerning for symptomatic cholelithiasis with features of gallstone pancreatitis. In this video we demonstrate that laparoscopic cholecystectomy with intraoperative cholangiogram is safe during all stages of pregnancy, limits harmful ionizing radiation to mother and fetus (especially when compared to ERCP), and ultimately limits the known extraordinarily high recurrent rates of those pregnant patients with gallbladder symptoms who do not undergo cholecystectomy when indicated. V228 Robotic Resection of Type I Choledochal Cyst with Roux-en-Y Hepaticojejunostomy and Hutson Access Loop Reconstruction Felix G del Rio, MD; Kevin Carroll, SO; Gary Deutsch, MD; South Shore University Hospital A 28-year-old female with an incidental finding of a Type I Choledochal Cyst (TICC) confirmed by CT, MRI and EGD/EUS. Given her young age and lifetime theoretical risk of developing cholangiocarcinoma, a robotic resection of TICC with Roux-en-Y Hepaticojejunostomy was performed. Given the patient's relatively small common bile duct diameter, normal wall thickness, and difficult postoperative access, a Hutson Access Loop Reconstruction was created. A ureteral stent was tunneled percutaneously into the jejunal access loop and subsequently through the anastomosis into the right hepatic duct. The stent served as an internal–external biliary drain for future access, if required. V229 Laparoscopic Sugarbaker Repair of Recurrent Parastomal Hernia with Innovative Method for Mesh Fixation David G Ortega, Research Fellow; Abhi Gupta, Resident Physician Grad Year IV KSOM Sur; Andrea Madiedo, MD, Resident of Surgery; Joongho Shin, Clinical Associate Professor of Surgery; Sarah Koller, Assistant Professor Of Clinical Surgery; University of Southern California, Department of Colorectal Surgery Parastomal hernias occur frequently following stoma creation. The Sugarbaker approach for parastomal hernia repair is an effective method of repair shown to have low recurrence rates. Fixing the mesh to the fascia can be cumbersome and usually involves a combination of pre-placed sutures and abdominal tacks. In this video, we present a laparoscopic Sugarbaker repair of a recurrent parastomal hernia using an innovative method for mesh fixation. Our goal is to offer another means of securing a sub-lay, intraperitoneal mesh laparoscopically in a patient with a complex medical and surgical history. V230 Robotic Assisted Repair of Subxiphoid Hernia Raye Ng, MD; Lauren E McClain, MD; University of New Mexico Incisional hernias are common however subxiphoid incisional hernias after coronary artery bypass grafts are incredibly rare. Here we present a concurrent robotic-assisted repair of a hiatal and subxiphoid ventral hernia. A 70yo male who underwent a CABG four years ago for CAD presented with GERD and a symptomatic ventral hernia. He had a 3 × 5 cm hernia with xiphoid dehiscence. A preperitoneal synthetic mesh was used to repair the defect with anchoring sutures at the periosteum of the subxiphoid in addition to a standard hiatal hernia repair with Nissen fundoplication. The patient tolerated the surgery and postoperative course well. V231 Laparoscopic Cholecystectomy via Laennec Approach Through the Cystic Plate for Gallbladder Stone with Type II Mirizzi Syndrome (With Video) Decai Yu; Laizhu Zhang; Jin Peng; Nanjing University To search for a new anatomical method for the anatomy of the gallbladder triangle for come bile duct reconstruction for the treatment of type II Mirrizi syndrome, we found that the Laennec membrane was a natural anatomical structure. We have performed a laparoscopic cholecystectomy (LC) via the Laennec approach through the cystic plate to avoid choledochojejunostomies for the successful treatment of Type II Mirrizi syndrome. The patient was discharged on postoperative day 7 without complications. The tomogram performed 6 weeks after surgery demonstrated well. It may be a safe starting point for LC to treat Type II Mirrizi syndrome. V232 Laparoscopic Dissection Lymph Node Station 16 Why and How? William Kawahara, MS 1; Eduardo A Vega, MD2; Eran Brauner, MD2; Omid Salehi, MD2; Sebastian Mellado, MS1; Oscar Salirrosas, MD2; Richard Freeman, MD2; Claudius Conrad, MD2; 1Tufts University School of Medicine, Boston, MA, USA; 2Department of Surgery, Saint Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA In this video we demonstrate how to perform a minimally invasive laparoscopic dissection of station 16 lymph nodes for staging of patients with colorectal, pancreatic, gastric, and hepatobiliary cancers. We will cover background information, operating room setup, surgical port positioning, hepatic flexure mobilization, kocherization, left renal vein identification, lymph node dissection, and important points to consider when performing this procedure. V234 Combined Endoscopic Laparoscopic Surgery for Benign Colorectal Disease Abhinav Gupta, MD; Sarah Choi, MD; Sarah Koller, MD; Kyle G Cologne, MD; Sang W Lee, MD; University of Southern California An increasing number of colectomies are being performed yearly for benign colorectal disease. Combined Endoscopic Laparoscopic Surgery (CELS) is an evolving approach to non-malignant colonic polyps that can potentially save patients from undergoing colon resection. This video hopes to highlight the utility and feasibility of CELS while stimulating all endoscopists to consider a breadth of treatment options when faced with a "difficult" colorectal polyp. V235 Laparoscopic Assisted Endoscopy for Severe Remnant Gastritis M. Siobhan Luce, MD, MPH; Mohammad S Sultany, MD; Cameron Gaskill, MD, MPH; Shushmita M Ahmed, MD; Department of Surgery, UC Davis School of Medicine We present the case of a patient with remote history of Roux-en-Y gastric bypass presenting with severe abdominal pain and melena in the setting of chronic NSAID use. Cross sectional imaging showed layered blood in the remnant stomach. Laparoscopic assisted endoscopy (LAE) of the gastric remnant was performed for further evaluation. Endoscopy showed severe gastritis of the remnant stomach and no mass. Despite negative barium swallow, gastrogastric fistula was seen on endoscopy. Final pathology showed chronic gastritis and metaplasia without malignancy. In summary, remnant gastritis is rare; LAE is useful for thorough gastric evaluation and to rule out malignancy. V236 Robotic-Assisted Laparoscopic Redo Hiatal Hernia Repair and Fundoplication Leo T Li, MD 1; Julissa Jurado, MD2; David Zeltsman, MD2; Lawrence Glassman, MD2; Kevin Hyman, MD2; Paul C Lee, MD, MPH2; 1Northwell Health North Shore/Long Island Jewish General Surgery, Manhasset, NY; 2Department of Cardiovascular and Thoracic Surgery, Long Island Jewish Medical Center, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell This is a “State of the Art” video demonstrating the feasibility of robotic-assisted laparoscopic redo hiatal hernia repair with Nissen fundoplication in a patient with hernia reoccurrence after initial repair and fundoplication 3 years prior. We hope to show that using the robotic platform is not only a safe approach, but its ability to magnify the surgical field and workability in the tight esophageal hiatus makes it our preferred method of surgery in patients with previous repair. V237 Combining the Bottom-Up Approach of Robotic CME with the Concept of Critical View During Robotic RT Hemicolectomy: a Thorough Comprehension of the Operative Plane and Vital Landmarks Siripong Cheewatanakornkul, DR; Piyanun Wangkulangkul, MD, PHD; Supakool Jearanai, MD; prince of Songkla University The most severe complication of CME is unintentional vascular injury, which is typically related to surgical technique or exposure. It is the result of a misunderstanding between the complexity of the vascular structure of the rt colon and the fusion plane. By separating plane into four pages, this technique not only highlighted the exposure of the rt colon, but also provided a clear view of the vascular landmarks. This video provided a bottom-up strategy for robotic-assisted CME that, when combined with the concept of standardization and vital landmarks, offers surgeons a comprehensive understanding of the operative plane and vital landmarks. V238 Robotic-assisted Revision of Gastric Bypass and Repair of Paraesophageal Hernia Chad C Griesbach, MD; Monique O Hassan, MD, MBA, FACS, FASMBS, DABOM; Baylor Scott & White—Temple This presentation focuses on the robotic-assisted revision of gastric bypass and paraesophageal hernia repair. Our patient presented with GERD and weight reoccurrence following a Roux-En-Y Gastric Bypass in 2014. Intraoperatively, there were dense adhesions requiring meticulous dissection. The gastric pouch was dilated, and the decision was made to revise the gastric pouch. The patient greatly benefited from the revision of her gastric bypass, evident by the resolution of her GERD symptoms and weight loss. This minimally invasive approach is proven safe in complex revisional bariatric surgery with low rates of postoperative complications. V239 Robotic Intracorporeal Rectus Aponeuroplasty (R-LIRA): A New Technique in the Management of Ventral Hernia Cristhian Valor, MD; Nicole Lopez-Canizares, MD; Alexandra Argiroff, MD, FACS; Flavio Malcher; NYU Langone Described by Salvador Morales-Conde in 2018, the Laparoscopic Intracorporeal Rectus Aponeuroplasty (LIRA) is a safe and effective alternative to a conventional laparoscopic ventral hernia repair. LIRA allows for tension free reconstruction of the midline via plication of both rectus muscles aponeuroses. The repair is reinforced with an overlapping intraperitoneal underlay mesh. This procedure can be modified to be done robotically as presented in this video. To date, there has been no reported complications in the literature with the use of this technique, however longer follow up and studies with larger sample sizes are needed to validate this procedure. V240 Medial to Lateral Approach: Laparoscopic Sigmoidectomy with Anomalous Inferior Vena Cava Martin Uwah, MD; Liam Devane, MD; John RT Monson, MD; Matthew Albert, MD; AdventHealth Orlando This is a video case report demonstrating laparoscopic sigmoidectomy with an infra-IMV, medial to lateral approach. This technique was employed in the setting of a patient with an anomalous, left-sided IVC and demonstrates the feasibility of this approach. V241 An Unusual Case of an Obturator Hernia Michelle Chang, MD; Omid Rahimi, MD, MPH; Christian Twiss, MD; Iman Ghaderi, MD, MSc, MHPE; University of Arizona We present an unusual case of obturator hernia in a patient who presented with right lower extremity neuropathy after excision of a retropubic urethral sling mesh. The hernia was successfully repaired by a robotic assisted laparoscopic transabdominal preperitoneal (TAPP) approach. To delineate the anatomy, the bladder was inflated with saline, and a fat containing obturator hernia was located and reduced. Prolene soft mesh was placed to cover the obturator foramen. Postoperatively, the patient's right leg neuropathy resolved and there were no complications. This case highlights successful and safe use of the robot for repair of an obturator hernia. V242 The Use of Augmented Reality Simulators in Laparoscopic Surgical Training Courtney Ludick, Ms1; David Rawaf, Dr2; Elliot Street, Dr2; Ross Davies 2; 1Nottingham Trent University; 2Inovus Medical/NHS This study aims to determine the suitability of AR simulation for laparoscopic surgical training through a systematic literature review. From a variety of databases, 26 papers were extracted. The current simulators on the market vary in price, modules, assessment metrics and feedback methods. AR provided faster skill acquisition and was widely preferred. Whether it is worth incorporating into the curricula depends upon its effectiveness which can be determined through its ability to aid skill acquisition, user opinion and justification of its cost. AR simulation has the potential to become the new gold standard for laparoscopic surgical training, and beyond. V243 Transanal Rectal Mucosectomy and Muscular Plication for Rectal Prolapse Christian Saliba; Christopher Blewett; Shin Miyata, MD; Cardinal Glennon Children's Hospital Patient is placed in prone position. First step after reducing the prolapse is to identify the pectinate zone with retraction 1 cm proximal to it. We placed multiple stay sutures in the rectum, 2 cm proximal to the pectinate zone. The muscular cuff is created by dissecting the muscularis from the submucosa until obtaining 1.5–2 times the prolapse length. The muscularis is then plicated at 3, 6, 9, 12 O’clock position and in-between sutures. The proximal colon is then anchored to the surrounding rectal mucosa with a full thickness suture. The mucosectomy is then performed and the colorectal anastomosis is completed. V244 Step Up Approach for Treatment of Epiphrenic Diverticulum Sharan Poonja, BS; Robert Acho, DO; Christopher DuCoin, MD; University of South Florida Morsani College of Medicine We will be presenting 2 different approaches to resect an epiphrenic mid/distal esophageal diverticulectomy: transthoracic and transabdominal. We will also be discussing the key steps to each surgery with 2 different cases of patients who present with similar symptoms and diagnosis. Both cases were performed via robotic approach and both patients were discharged without complications. Our step up approach displays a safe algorithm for the treatment of epiphrenic diverticula. V245 Robotic e-TEP for a Right Upper Quadrant Incisional Hernia Repair with Left Lateral Docking in a Patient with Severe Morbid Obesity Joseph Nguyen-Lee, MD, MEd 1; Roberto Secchi del Rio, MD2; Daniel Tomey, MD3; Rodolfo J. Oviedo, MD, FACS, FASMBS, FICS1; 1Houston Methodist Academic Institute; 2Universidad Anahuac Queretaro, Mexico, School of Medicine; 3The University of Zulia, Faculty of Medicine. Maracaibo, Venezuela Intraperitoneal implantation of the mesh has been related to an increased risk of complications. We perform a pre-peritoneal mesh placement whenever possible, to decrease these possible complications. For this patient with recurrent incisional hernia secondary to open cholecystectomy, we performed a repair using an extended totally extra preperitoneal (e-TEP) approach. The defect size was 6 × 9 cm, a 15 × 20 cm mesh was placed in the pre-peritoneal space, operative time was 167 min, length of stay was 2 days, and 1-year follow-up showed no complications. By placing the mesh in the pre-peritoneal space, we can diminish the potential risks associated with an intraperitoneal mesh. V246 An Interesting Case: Robotic Assisted Revision of Gastrojejunostomy and Partial Gastrectomy Alex S Kremers, MD; Brittany Mead, MD; Benjamin Veenstra, MD; Rush University Medical Center This is an interesting video case of a Robotic-assisted revision of a gastrojejunostomy and partial gastrectomy. The patient had a history of a perforated gastric ulcer and graham patch, and subsequently underwent antrectomy and vagotomy. She had developed PO intolerance and TPN dependence. An endoscopy demonstrated redundancy in her remaining stomach. We performed a robotic assisted partial gastrectomy of her redundant stomach and resected her gastrojejunostomy. We then created a new gastrojejunostomy with hopes of relieving her symptoms. V247 The Difficult Gallbladder: Robotic-Assisted Subtotal Reconstituting Cholecystectomy Julia Button, MD; Amy Holstrom, MD; Gregory Dakin, MD, FACS, FASMBS; Cheguevara Afaneh, MD, FACS, FASMBS; Omar Bellorin-Marin, MD, FACS, FASMBS; New York Presbyterian-Weill Cornell 53-year-old male with complex medical history presented to the Emergency Room with recurrent abdominal pain. He was diagnosed with acute cholecystitis on imaging. He had previously been treated three times for acute cholecystitis by medical with intravenous antibiotics and cholecystostomy tube placement. During this most recent presentation to the Emergency Room he was noted to have cholecystostomy tube dislodgement. The decision was made for the patient to undergo robotic-assisted subtotal cholecystectomy. Operation went well and patient was discharged on post-operative day 2 on a regular day. V248 Robotic Partial Splenectomy for Pseudocyst Jordan R Purewal, MD; Justin Dhyani, MD; Seth Kipnis, MD, FACS, FASMBS; Jersey Shore University Medical Center We performed a robotic partial splenectomy for a symptomatic pseudocyst. Currently this procedure is performed by open or laparoscopic techniques. We show that robotic assisted surgery is a safe treatment option when faced with cases such as this. V249 Large Paraesophageal Hernia Encountered During Roux-en-Y Gastric Bypass: What to Do? Chau M Hoang, MD, MSCI 1; Juan C Garces, MD2; George Ferzli, MD, FACS3; 1NYC Health + Hospitals/Kings County; 2NYC Health + Hospitals/Jacobi Medical Center; 3NYU Langone The patient with morbid obesity and known hiatal hernia presented for laparoscopic R-en-Y gastric bypass. Intra-op, we found a large paraesophageal hernia. We created the jejunojejunostomy first, as was our standard. Then we dissected the gastrosplenic ligament, and along the left crus, followed by opening the clear area of the gastrohepatic ligament, dissecting along the right crus. Blunt dissection was carried to the mediastinum, the esophagus was circumferentially freed, and hernia sac was reduced. Crura were reapproximated. After creation of the gastrojejunostomy, the remnant stomach was used for fundoplication, with additional anchoring to the crura. No mesh was needed. V250 Laparoscopic Low Anterior Resection with Natural Orifice Specimen Extraction Pavan Kumar Jonnada; Kvvn Raju; Pradeep Keshri; Sri Siddartha Nekkanti; Zeeba Usofi; BIACHRI This is a video demonstration of laparoscopic low anterior resection with natural orifice specimen extraction for the resection of tumours of the rectum. This novel technique aims to achieve clear circumferential margins of the mesorectum and scarless surgery. The complications after this technique are acceptable without compromising the oncological outcomes. Hence, we describe about this procedure and describe in detail. V252 Robotic Anatomical Right Hepatectomy. Description of Surgical Technique Kawtar S Guenoun; Melissa Touadi; Sharona Ross; Iswanto Sucandy; Advent Health 18 y/o female presented with 2-year constant severe RUQ abdominal pain that radiates to her back, vomiting, and weight loss. CT scan revealed an encapsulated enhancing 9 cm lesion consistent with hepatic neoplasia near the root of right hepatic vein. The procedure started with isolation and ligation of the right anterior and posterior hepatic artery and portal vein. A total anatomical right hepatic lobectomy was completed uneventfully with demonstration of each surgical steps. The use of intraoperative ICG fluorescent angiography was also demonstrated. Patient did very well and was discharged home on POD3. V253 Robotic-assisted Redo Gastrojejunostomy Rocio Castillo Larios, MD; Michel Cordies Perez, MD; Lorna Evans, MD; Alvaro Ducas, MD; Enrique F Elli, MD, FACS; Mayo Clinic Florida Roux-en-Y Gastric Bypass (GB) is one of the most commonly performed bariatric surgeries. Although it has been demonstrated that Roux-en-Y GB significantly reduces weight and obesity-related complications, this procedure is not free from unwanted side effects. Long-term complications of this surgery include dumping syndrome, strictures, marginal ulcers, fistulas, and nutritional deficiencies. We present the case of a 42-year female with a history of chronic nausea and vomiting post Roux-en-Y GB complicated with pouch ulceration and stenosis of the gastrojejunal anastomosis. V254 Paraesophageal Hernia Repair With Magnetic Sphincter Augmentation: How We Do It Joseph P Bethea, MD; Robert Allman, MD; Brandon S Peine, MD; James E Speicher, MD; Mark Iannettoni, MD; Carlos J Anciano, MD; Aundrea Oliver, MD; East Carolina University Health This is a video depiction of how we perform a paraesophageal hernia repair with magnetic sphincter augmentation and gastropexy at our institution. The video depicts our technique in a patient who had textbook anatomy. V255 Robotic Assisted Roux-en-Y Gastric Bypass and Type III Hiatal Hernia Repair with Mesh in a Patient with Incidental Malrotation Dessislava I Stefanova, MD; Amy Holmstrom, MD; Gregory Dakin, MD, FACS, FASMBS; Cheguevara Afaneh, MD, FACS, FASMBS; Omar Bellorin-Marin, MD, FACS, FASMBS; Weill Cornell Medicine The incidence of malrotation is estimated to be one in six thousand births. This video depicts a robotic Roux-en-Y gastric bypass and hiatal hernia repair in a patient with incidental midgut nonrotation. The procedure was approached by hiatal hernia reduction followed by gastric pouch creation. The ligament of Treitz and entirety of the small intestine were identified to the patient's right and the colon to the left. There were minimal Ladd's adhesions and no evidence of intestinal volvulus. The procedure was performed with the blind end of the alimentary limb facing the patient's right avoiding twisting of the mesentery. V256 Robotic Distal Gastrectomy with Billroth II Reconstruction Michelle M Dugan, MD 1; Sharona Ross, MD2; Iswanto Sucandy, MD2; Alexander Rosemurgy, MD2; 1Florida Atlantic University; 2Digestive Health Institute Tampa This video demonstrates a robotic distal gastrectomy for chronic gastric outlet obstruction. CT with diffuse pyloric thickening without surrounding lymphadenopathy. Multiple EGDs with biopsies all revealed benign pathology. The patient failed weeks of non-surgical management. Attempt at duodenal stent placement was unsuccessful. Pre-operative diagnosis was consistent with benign pyloric stricture secondary to suspected ulcerative disease. However, intraoperative evaluation was highly suspicious for malignancy. Frozen pathology returned positive for carcinoma with positive margins. Additional margins were resected as well as D2 lymphadenectomy. An antecolic Billroth II reconstruction was created. Final pathology with gastric adenocarcinoma pT4a, negative margins, 23 negative lymph nodes. V257 Closure of Mesenteric Defects in RNYGBP: Does It Make a Difference? Shravan Sarvepalli, MD; Daniel Praise Mowoh, MD; Karan Grover, MD; Mujjahid Abbas, MD; University Hospitals of Cleveland This video demonstrates that even in patients that underwent mesenteric defect closure during the index operation, there is a risk of re-opening of the defect. Currently, there is insufficient evidence regarding the risk reduction of development of internal hernia associated with closure of mesenteric defects. Depending on the method, closure of the mesenteric defect can be technically difficult and add to operative time and result in complications such as kinking of the JJ, bleeding and mesenteric hematoma formation. While mesenteric defects are routinely closed at our institution, non-closure is being considered due to these complications. V258 Robotic Hepatic Artery Infusion Pump Placement for Unresectable Colorectal Liver Metastases Kelly M Mahuron, MD; Laleh G Melstrom, MD; City of Hope National Medical Center Up to half of patients with colorectal cancer will develop liver metastases (CRLM), but only 15% have resectable liver disease. Resistance to chemotherapy is common, and there are no effective third line regimens. Hepatic artery infusion in combination with systemic chemotherapy has been associated with improved survival for unresectable CLRM patients. There is increasing interest in minimally invasive approaches for pump placement to shorten postoperative recovery and time to therapy initiation. Our video demonstrates robotic-assisted hepatic artery infusion pump placement for a patient with unresectable CLRM who progressed on multiple lines of chemotherapy. V259 A Uniquely Difficult Gallbladder: Subtotal Cholecystectomy with Partial Colectomy for Cholecystocolonic Fistula Eleanor R Johnson, MD, MPH; Megan E Campany; Ga-ram Han, MD; Britton B Donato, MD, MPH, MS; Irving A Jorge, MD, MBA, FACS; Mayo Clinic Arizona The difficulty of gallbladder dissection during laparoscopic cholecystectomy ranges from straightforward to complex. Difficult gallbladder dissections could be more likely in patients with long-standing symptoms and evidence of chronic cholecystitis. Demonstrated here is a uniquely difficult case of an 88-year-old male with chronic cholecystitis who underwent laparoscopic cholecystectomy that was complicated by cholecystocolonic fistula. Due to the complexity of the case, he ultimately underwent subtotal cholecystectomy with partial colectomy. Intraoperative cholangiography was performed to safely identify the common bile duct. The presentation of this case demonstrates how a difficult gallbladder dissection can be performed safely without postoperative complications. V260 Robotic Partial Duodenectomy for Duodenal Gastrointestinal Stromal Tumor Justin Lee; Colby W Clark; AdventHealth Tampa This is a case report of a 65 year old female with no significant past medical history, surgical history of a Left Nephrectomy for renal cell carcinoma who was found to have a biopsy proven 1.8 cm periampullary Gastrointestinal Stromal Tumor. Due to the location of the tumor, a pancreaticoduodenectomy was discussed with the patient. However, robotic assisted excision of the tumor was also presented as an option. The patient underwent a robotic partial duodenal excision of the Gastrointestinal Tumor with negative margins. Postoperatively, the patient had an uneventful course and was spared the morbidity of a pancreaticoduodenectomy. V261 De Garengeot Hernia Shawn Moore, MD; Bradley Pansing, MD; Georg Wiese, MD; Advent Health Orlando An otherwise healthy female patient in her 30's presented to the emergency department with a painful bulge in the right inguinal region. Vital signs and laboratory evaluation were unremarkable. A CT scan showed a right femoral hernia with a 7 mm neck containing fat and the tip of the appendix (De Garengeot hernia) with stranding and fluid consistent with tip appendicitis. She was taking for a laparoscopic appendectomy and incarcerated right femoral hernia repair with mesh. V262 Fenestrated Subtotal Cholecystectomy Elizabeth W Tindal, MD, MPH 1; Marcoandrea Giorgi, MD2; 1Brown University; 2The Miriam Hospiral This video depicts a fenestrated subtotal cholecystectomy utilizing an endoscopic suturing device to close the cystic duct orifice. A 53-year-old male presented with abdominal pain and was found to have acute cholecystitis with choledocholithiasis. Following ERCP, he was taken for a cholecystectomy. Given the extensive inflammation, a critical view of safety was not possible and a subtotal cholecystectomy was performed. The cystic duct orifice could be visualized but not isolated further. Using an endostitch device, we were able to safely and effectively oversew the orifice. The patient had no bile leak postoperatively, recovering well with no need for additional interventions. V263 Robotic Re-operation for Leakage of Graham Patch Andrea Fa, MD; LSU HSC New Orleans We present a case of robotic modified graham patch of a perforated duodenal ulcer. Our patient is a 78-year-old man who presented with a 1-day history of worsening abdominal pain and free air on CT scan. Initial diagnostic laparoscopy showed a 1 cm perforated ulcer in the 1st portion of the duodenum. He underwent laparoscopic graham patch repair but developed atrial fibrillation and worsening abdominal pain postoperatively. Imaging showed a persistent leak at the repair site. He then underwent robotic re-do modified graham patch repair. We demonstrate our technique for this redo repair and the patient's postoperative course. V264 Laparoscopic Conversion of Gastric Plication to Roux-en-Y Gastric Bypass Dylan Cuva, MD; Chau Hoang, MD; Manish Parikh, MD; John Saunders, MD; NYU Langone Health/Bellevue Hospital Center Laparoscopic Gastric Plication has been re-introduced in the last decade as an investigational alternative to Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass for weight loss surgery. However, it has been associated with a high prevalence of reoperation for post-operative complications. Presented is a case of a patient who previously received a Laparoscopic Gastric Plication, now presenting with one year of increasing abdominal pain and PO intolerance. This patient was found to have a large gastric diverticulum with intermittent intussusception, leading to her symptoms, which required conversion into Roux-en-Y Gastric Bypass. V265 The Use of Functional Luminal Imaging Probe (FLIP) to Tailor Intraoperative Technique Hemasat Alkhatib, MD; AJ Haas, MD, MMSc; Clara K Lai, MBBS; Angela Thelen, MD, MHPE; Kelly Zhang, MD; Alejandro Feria, MD; Sergio Bardaro, MD, FACS, FASMBS; Amelia Dorsey, MD; Kevin El-Hayek, MD, FACS; The Metrohealth System The use of Flip Technology in foregut surgery enables the surgeon to tailor their technique to best suit each individual patient. In this video, we present its use in Robotic Hiatal Hernia Repair, Heller Myotomy, and Fundoplication. We highlight how at each step; FLIP technology offers objective data that can alter intraoperative decision making and change management. V266 Laparoscopic Repair of Incarcerated Lumbar Hernias in Geriatric Patients Alexandra Z Agathis, MD; Asya Ofshteyn, MD, MPH; Hongdau Liu, MD, PhD; Edward Chin, MD; Icahn School of Medicine at Mount Sinai We present two cases of symptomatic geriatric patients, a 94-year-old and 80-year-old female with incarcerated right and left lumbar hernias. CT scans each revealed a lumbar hernia containing non-obstructed colon. Given the patients' discomfort and independent baseline functional status, they opted for elective operative repairs. Using an intraperitoneal laparoscopic approach, a polyester mesh was secured with transfascial sutures and titanium tacks. Special attention was made to preserve the lateral femoral cutaneous and femoral nerves. Postoperative courses were uncomplicated, with patients returning to their baseline. This video demonstrates an effective treatment approach for this uncommon pathology in nonagenarian and octogenarian populations. V267 Endoscopic Ultrasound Anatomical Landmarks in Endoscopic Sleeve Gastroplasty Pietro Riva, MD 1; Elisa Reitano, MD1; Leonardo Sosa, MD2; Alfonso Lapergola, MD3; Jacques Marescaux, MD, FACS, HonFRCS, HonFASA, HonAPSA1; Silvana Perretta, MD, PhD1; 1IRCAD France; 2IHU Strasbourg France; 3Nouvel Hôpital Civil, CHRU-Strasbourg, Strasbourg, France Endoscopic sleeve gastroplasty is a promising endoluminal bariatric procedure, Gastric plication is achieved by multiple full-thickness sutures applied endoscopically. A good understanding of gastric anatomy inside-out is key to prevent complication related to inadvertent injury of adjacent organs and to achieve adequate gastric restriction. This video demonstrates the landmarks that should guide the placement of endoscopic sutures and the underlying anatomical structures that should be preserved using a EUS and a dedicated virtual simulator. A good understanding of 3D gastric anatomy is fundamental to democratize the safe introduction of ESG and can be supported by VR simulation and EUS. V268 Robotic Assisted eTEP TAR Repair for Incisional Urinary Bladder Hernia with Bilateral Groin Hernias Noppol Feuangwattana, MD; Piyanun Wangkulangkul, MD, PhD; Siripong Cheewatanakornkul, MD; Prince of Songkla University Hospital A 73-year-old male presented with reducible masses at suprapubic area and both groins for 6 months. He had previously undergone numerous operations to treat his left groin hernia (1985, 2009, and 2022), the most recent of which necessitated an open midline incision to treat his herniated urinary bladder. Physical examination revealed significant reducible masses at both groins, the suprapubic region, and the umbilical region. Prior to the procedure, a CT scan was done to assess the extent of the defects. We decided to perform robotic assisted eTEP TAR repair for incisional urinary bladder hernia with bilateral groin hernias. V269 Robotic Preperitoneal Morgagni Hernia Repair with Self-Fixating Mesh Adam Berenson, MD; William Richardson, MD; Ochsner Clinic Foundation Morgagni hernias are anterior diaphragmatic defects within the space between the xiphoid process and the costal portion of the diaphragm. These are particularly rare in adults. In our video, we demonstrate a robotic preperitoneal repair of a Morgagni hernia. Our patient is a 44-year-old female with associated epigastric and chest pain, dyspnea, and vomiting. We first reduced the transverse colon from the defect, then created a preperitoneal flap. We achieved primary closure of the defect, followed by self-fixating mesh coverage. With the repair, our patient's symptoms improved and she has not had recurrence after four months of follow-up. V270 Small Bowel Obstruction after Jejunostomy Tube Placement in patient with Roux-en-Y Gastric Bypass Adam D Reese, MD1; Ivanesa Pardo, MD 2; 1MedStar Georgetown University Hospital, MedStar Washington Hospital Center; 2MedStar Washington Hospital Center While the feeding jejunostomy plays an important role in enteral nutrition, jejunostomy-related complications, including bowel obstruction, are well described. Presented here is a case of small bowel obstruction after recent jejunostomy tube placement in a patient with a remote history of Roux-en-Y gastric bypass. Placement of the jejunostomy at the jejunojejunal anastomosis significantly increased the risk of complication and led to the obstruction requiring laparoscopic enterolysis. We conclude that in patients who require feeding jejunostomy after Roux-en-Y Gastric Bypass, selection of the optimal jejunostomy tube site requires careful consideration of the anatomy in order to prevent future complications. V271 Robot-Assisted Esophagectomy with Extended Mediastinum Lymph Node Dissection Hirofumi Kawakubo, MD, PhD; Masashi Takeuchi; Satoru Matsuda; Yuko Kitagawa; Keio University School of Medicine We introduced robot-assisted esophagectomy (RMIE) with extensive mediastinum lymph node dissection using da Vinci Xi system. We show safety introduction and technical pitfalls of RAMIE. After esophageal mobilization and mediastinal lymphadenectomy were completed, bilateral recurrent laryngeal nerve, bilateral subclavian artery, trachea, bilateral bronchus, aorta, left pulmonary artery and vein, left pleura, pericardium and hiatus are all skeletonized. Average operation time in the thoracic procedure is 215 min, median blood loss is 0 ml and vocal cord palsy was occurred only 5 case in last 60 cases. RAMIE with extended LN dissection is feasible and beneficial for the extended mediastinum lymph node dissection. V272 Robotic Deceased Donor Renal Transplantation Angela L Hill, MD; Meranda Scherer, RN; Darren R Cullinan, MD; Gregory Martens, MD, PhD; Adeel S Khan, MD, MPH, FACS; Washington University in St. Louis This video demonstrates a robotic deceased donor kidney transplantation. It includes aspects related to patient positioning, port placement and surgical technique for vascular exposure, anastomoses and ureteral reconstruction. Also demonstrated is intraoperative ultrasound to assess renal vessels after retroperitonealization of the kidney. For this case, cold ischemia time was 20 h and warm ischemia time, 34 min. The patient had an uneventful recovery and has continued to do well with excellent renal function. This video narrates the technical steps of the operation and highlights potential advantages with regards to visualization, quality of dissection and anastomosis and small size of incision. V273 Laparoscopic Transgastric Resection of a Symptomatic Gastroesophageal Junction Leiomyoma Carlos Delgado, MD; Advent Health Orlando Submucosal esophageal tumors are rare neoplasms that can become symptomatic requiring surgical resection. Although mostly benign, discomfort and increased aspiration or dysphagia risks can occur. Our videoed patient was incidentally found to have a GEJ leiomyoma that became symptomatic. CT revealed tumor location and lymphadenopathy. Endoscopic ultrasonography with biopsy evaluated the tumor extension and confirmed its benign pathology. A laparoscopic transgastric resection was performed based on prior data and papers validating its safety, feasibility, and oncologic efficacy weighed against stricture, bleed, or perforation risks of the gastroesophageal junction. The video shows our operative process and the patient's uneventful postoperative course. V274 Laparoscopic Roux en Y Gastric Bypass with Handsewn Gastrojejunostomy and ICG Claire L Terez, MD; Keith King, MD; Christopher Buccholz, DO; Lora Melman, MD; Michael Donaire, MD; Ragui Sadek, MD; Advanced Surgical and Bariatrics of New Jersey This video demonstrates a state of the art performance of a laparoscopic roux en Y gastric bypass with hand sewn gastrojejunostomy using ICG technology. The basic steps include, port placement, creation of the bilopancreatic limb, creation of the jejunojeunostomy, closure of the potential spaces, division of the omentum, creation of the gastric pouch, the gastrojejunostomy and concluding the procedure with a leak test. The ICG fluoresence ensures all bowel is well perfused throughout the duration of the procedure. V275 Laparoscopic Repair of Internal Hernia Between Gastrojejunal Anastomosis and Remnant Stomach After Roux-En-Y Gastric Bypass Kevin Chin, MD; Benjamin Shadle, MD; Subhash Reddy, MD; Sutter Health Introduction: Traditionally, internal herniation after Roux-En-Y Gastric Bypass has been at three locations: the jejunojejunostomy mesenteric defect, Petersen's defect (bordered by the roux limb mesentery, transverse mesocolon, and retroperitoneum), or transverse mesocolon. This case report highlights the diagnosis of internal hernia after Roux-En-Y Gastric Bypass at an uncommon location: the defect between the proximal Roux limb next to the gastrojejunal anastomosis and the remnant stomach. Procedure: Laparoscopic reduction and repair of the internal hernia was performed with defect closure. Conclusion: Internal herniation as a post operative complication can still occur at uncommon locations despite closure of common defect sites. V276 A Novel Trananal Minimally Invasive Approach For Division Of Colonic J Pouch Septum After Coloanal Anastomosis For Rectal Cancer Aisha Akhtar; George Apostolides, MD; Greater Baltimore Medical Center The colonic J-pouch creates to improve functional outcome after proctectomy with coloanal anastomosis. Sometimes an apical pouch bridge remains as residual septum above colonic J-pouch anal anastomosis causing low anterior resection syndrome. Division of septum can resolve symptoms by increasing the reservoir capacity. We describe a successful TAMIS technique for division of an apical pouch bridge on a 59 years old patient. Symptoms related to the apical pouch bridge were resolved immediately. An apical septal bridge after colonic J pouch anal anastomosis may cause debilitating LAR syndrome. A TAMIS approach can be utilized to divide the septum with endoGIA stapler. V277 Laparoscopic Transgastric Resection of a Gastroesophageal Leiomyoma Dalia Albloushi, MD 1; Omar AlQabandi, MD2; Danah Quttaineh, MD2; Muneerah AlMuhaini, MD2; Abdullah Alfawaz, MD3; Ali Alali, MD1; Salman Alsafran, MD3; 1Mubarak Alkabeer Hospital; 2Jaber Alahmed Hospital; 3Kuwait University Faculty of Medicine Leiomyomas are common smooth muscle tumors of the stomach, compromising 80% of all gastric stromal tumors with one third of them located in the gastroesophageal junction. Surgical intervention typically warranted in large tumors. Minimally invasive techniques have been utilized for more favorable patient's outcomes. Management includes; endoscopic resection or surgical resection. We present this novel laparoscopic transgastric resection of a larger gastroesophageal junction leiomyoma. V278 Laparoscopic Management of Perforated Jejunal Diverticulitis with Active SARS-CoV-2 Pneumonia, in a Long Segment Jejunal Diverticulosis Taylor Loui; Indraneil Mukherjee; Staten Island University Hospital—Northwell Health 50F w/ PMH of GERD, depression, endometriosis, D&C, HTN, HLD, hypothyroidism, and COVID 19 presented to the ED with abdominal pain, found to have perforated jejunal diverticulitis. She was managed non-operatively with antibiotics and re-presented for elective small bowel resection. She underwent laparoscopic resection of around 100 cm of diverticular jejunum with primary anastomosis. V279 Robotic-assisted Nissen Fundoplication with Mesh Conversion in Roux-en-Y Gastric Bypass Alvaro Ducas, MD; Lorna Evans, MD; Rocio Castillo Larios, MD; Michel Cordies, MD; Fernando Elli, MD, FACS; Mayo Clinic 70-year-old patient presenting dysphagia and acid reflux. Previous paraesophageal hernia, underwent two laparoscopic Nissen fundoplication at another institution, the last one with mesh. In addition, the patient has severe GERD, esophageal dysmotility and obesity. Esophagram shows a portion of the wrap of the fundoplication extending superior to the hiatus. It was decided to perform a robot-assisted Nissen fundoplication conversion in Roux-en-Y gastric bypass. First day postoperative esophagram shows prompt passage of contrast through the esophagus and anastomosis. V280 Successful Endoscopic Closure of the Appendiceal Orifice Antoinette Hu, MD; Eric M Pauli, MD; Joshua S Winder, MD; Penn State Health Milton S. Hershey Medical Center Colocutaneous fistulas from ruptured appendicitis have traditionally been repaired surgically, but endoscopic approaches for fistula closure have been reported as safe and efficacious when possible. There are no reports describing endoscopic closure of the appendiceal orifice in a colocutaneous fistula using over the scope clips. In this video, we describe successful fistula closure in a surgically complex patient with a colocutaneous fistula by placing an over-the-scope clip over the appendiceal orifice, thereby avoiding the morbidity associated with a surgical repair. At two months' postoperative followup, there were no postoperative complications. V281 Laparoscopic Totally Extraperitoneal Herniotomy (TEP-Hy)—A Novel Procedure For Repair of Inguinal Hernia Without Posterior Wall Deficit in Young Adults Pawanindra Lal, MDFACSFRCSEdGlasgEngIrel; Anubhav Vindal, MDFACSFRCSEdGlasg; Maulana Azad Medical College, New Delhi, India Three midline ports are used as in TEP and extraperitoneal space is expanded such as to delineate the midline, inferior epigastric vessels and the cord structures. Extensive lateral dissection is avoided since no mesh is being placed. Indirect hernial sac is dissected off the cord avoiding the vas and sac is reduced completely. Complete sac is dissected circumferentially, scored with energy source with ligation of divided sac using endoloop. Hernial sac is dissected proximally until vas and spermatic vessels separate. Fascia transversalis of deep ring is closed in purse-string fashion with minimum three bites using non absorbable 00 Vloc suture. V282 Robotic-Assisted Laparoscopic Repair of Incarcerated Falciform Ligament Hernia Bilal Koussayer, BS 1; Sabrina Awshah, BS1; Joseph Sujka, MD2; Christopher DuCoin, MD, MPH, FACS2; 1USF Health Morsani College of Medicine; 2Bariatric & Foregut Surgery, Department of Surgery, University of South Florida Falciform ligament hernias are rare hernias that occur through an abnormal opening in the falciform ligament of the liver. Nevertheless, early and accurate management is crucial in preventing morbidity and mortality in these patients. In our report, we demonstrate that a robotic assisted laparoscopic approach is a safe and effective means of correcting this hernia. This is a case of a 38-year-old female who presented with a symptomatic enlarging ventral bulge near her umbilicus. A preoperative MRI revealed an incarcerated ventral hernia containing only fat. The patient was taken for robotic-assisted laparoscopic ventral hernia repair. V283 Laparoscopic Right Adrenalectomy for Giant Adrenal Myelolipoma Patrick H Meyer, MD; Carlos Delgado, MD; Steve Eubanks, MD; AdventHealth Orlando This video submission demonstrates a laparoscopic right adrenalectomy for a giant adrenal myelolipoma. There have been few previous case reports that have described and demonstrated a laparoscopic approach when performing a resection of a large tumor. There have been even less, to our knowledge, who have demonstrated a resection that matches the clarity and quality of this video submission. V284 Laparoscopic Assisted ERCP for CBD Stone Post OAGB with Prior Sleeve Gastrectomy Aly Elbahrawy, MD, FACS; Samah Melebari, MD; Alwahhaj Khogeer, MD; King Abdullah Medical City Common bile duct (CBD) stone after one anastomosis gastric bypass (OAGB) preceded by sleeve gastrectomy (SG) is having low incidence and therefore it may have been under-reported. In this video, we are reporting the management and challenges of laparoscopic assisted transgastric ERCP for symptomatic CBD stone post OAGB preceded by SG. V286 Gastric Stimulator Erosion into the Duodenum Caitlin Black, MD; Jennifer Allison, MD; Matthew Davis, MD; University of Tennessee Health Science Center Department of Surgery Gastric electrical stimulators have been safely and successfully used in the treatment of gastroparesis for over ten years. Though the most common complication of stimulator placement is infection of the pulse generator at the abdominal wall, the electrodes, placed in the gastric muscularis propria, have been reported to migrate through the gastric wall into the lumen of the stomach. This video features a unique case of gastric stimulator electrodes eroding into the duodenum with contained perforation. A combination of laparoscopy, endoscopy, and follow-up contrast study was used to successfully remove the leads without need for a larger intervention. V287 Robotic Hiatal Hernia After Open Roux-en-Y Jason Silvers, MD; Khea Tan, MD; Aamirah McCutchen; Seth Kipnis, MD, FACS, FASMBS; Jersey Shore University Medical Center We present the case of a 49-year-old female with a symptomatic hiatal hernia and history of open Roux-en-Y gastric bypass. Robotic hiatal hernia repairs are being performed with greater frequency due to their increased dexterity compared to the laparoscopic approach. Additionally, the robotic approach has been shown to benefit patients with previous foregut or bariatric surgery; however, the incidence of robotic hiatal hernia repairs after open Roux-en-Y gastric bypass is underreported in the literature. We aim to show the robotic approach is beneficial in these instances. V289 Continuous ICG Infusion During Distal Pancreatectomy: How to See the Pancreas Yuhamy Curbelo-Pena, MD; Núria Lluís, MD; Filipe Kunzler, MD; Horacio Asbun, MD, FACS; Domenech Asbun, MD, FACS; Miami Cancer Institute This video reports the usefulness of ICG infusion during laparoscopic distal pancreatectomy. 39-year-old female patient with a 4-cm mucinous cystic neoplasm in the pancreatic tail and splenic vessel abutment. The patient underwent a laparoscopic distal pancreatectomy using the clockwise technique. A continuous ICG infusion of 0.4 mg/min was begun at starting time. ICG fluorescent imaging was used intermittently throughout the procedure. The continuous infusion also allowed for the consistent appearance of the pancreatic parenchyma without abnormally bright fluorescence from surrounding structures. This tool appears to be safe and valuable during pancreatectomy, an area that is anatomically complex. V290 Laparoscopic Perineal Hernia Repair After Low Anterior Resection Biruk Almaz, MD; Rodney Kratz; Michael Russell, MD; Javier Herrera, MD; Swedish Medical Center Postoperative perineal hernia (PPH) after abdominoperineal resection (APR) is a well-known, however rare complication that has been described in the literature. However, to our knowledge, there is no reported PPH after diverticulitis or low anterior resection (LAR) in the literature. Our patient is a 64-year-old woman with magnetic resonance image findings of complicated diverticulitis with an abscess tracking from the sigmoid colon through the left levator muscles to the ishioanal space. The patient underwent uneventful Laparoscopic LAR and subsequently developed PPH after three months. Our video describes successful laparoscopic perineal hernia repair with mesh and rectopexy. V291 SP Robotic APR for the Treatment of T4b Rectal Cancer Hye-Jin Kim; Gyu-Seog Choi; Min Hye Jung; Kyungpook National University Chilgok Hostpial, Daegu, Korea This patient had rectal cancer which was suspected to invade the vagina and external anal sphincter muscle. After completion of preoperative chemoradiotherapy, SP robotic APR was performed. Operative time was 150 min and estimated blood loss was 10 mL. Hospital stay was 5 days and there was no postoperative complication. On pathologic examination, T4b, invasion of vagina was diagnosed. Harvested number of lymph nodes were 18, but no metastatic lymph node was identified. SP robotic APR is safe and feasible for the treatment of T4b rectal cancer. In addition, cosmesis can be maximized to use the intended colostomy site as the single-incision site. V292 Pulley Method for Mesh Deployment Jaclyn Heilman; Seth Newman, MD, FACS; Jefferson Abington Health We present a simple and cost-effective method to deploy mesh in robotic ventral hernia repairs. This method is advantageous as it requires an 8 mm port to insert mesh in the abdomen rather than a 12 mm port required for a pre-attached inflatable balloon-mesh system. After closing the defect with 1-PDS barbed suture 2.5× leaving the needle at the center, it is inserted through the mesh. The mesh is marked to indicate its center and rough side. Two unidirectional, 2–0 PDS sutures are used to secure the mesh to the abdominal wall starting in the 3 and 9 o'clock positions. V293 Acute Small Bowel Obstruction Following Robotic Trans-Abdominal Preperitoneal Umbilical Hernia Repair Keaton L Altom, MD; Kathleen C Clement, MD; Tripler Army Medical Center This is a case of a 29-year-old male with a fat-containing umbilical hernia who underwent robotic trans-abdominal preperitoneal umbilical hernia repair with mesh. A small peritoneal defect was repaired with V-loc suture. The patient re-presented postoperative day 2 with acute small bowel obstruction (SBO) with transition point located posterior to the rectus muscle at the level of the umbilicus. The patient was taken back to the operating room for exploration and found to have a V-loc suture that had pulled through and became caught in the bowel mesentery, causing an SBO. This was removed, and the patient recovered without complication. V294 Ladd's Procedure for Recurrent Pancreatitis in Adult Malrotation Eric Skaggs, MD; Laura Fischer, MD, MS, FACS; Amir Rumman, MD, FRCPC; Fernando Mier, MD; University of Oklahoma This video describes a laparoscopic Ladd's procedure in adult man who was recently diagnosed with adult malrotation after multiple years of recurrent pancreatitis. The patient previously had a pancreatic stent placed which improved his symptoms, but was only a temporary solution. The key goal of the procedure was to mobilize the entirety of the duodenum, straighten it out, and remove any kinking that may potentially cause obstruction at the ampulla of Vater thus causing his recurrent pancreatitis. After the procedure, patient has not had any episodes of acute pancreatitis. V295 Laparoscopic Splenectomy for Left Side Portal Hypertension Allison Harmon; Laura Fischer, MD, MS; Fernando Mier Giraud, MD; University of Oklahoma Patient presented with hematemesis and on imaging, gastric varices and splenic vein thrombosis. Diagnosed with Sinistral hypertension. MIS consulted for a laparoscopic splenectomy. Splenectomies in cases with varices have increased risk of bleeding due to enlarged veins and more friable vessel walls. Dissection of the spleen started from the inferior pole through adhesions, where bleeding was encountered. In order to avoid further bleeding, strategy switched to ligating varices individually with advanced bipolar ligature and stapler. Dissection of the splenorenal, splenophrenic and hilum occurred with less bleeding. Patient had a normal post-operative recovery and has had no further episodes of emesis. V297 Robotic Repair of Chronic Spigelian Hernia and Ipsilateral Inguinal Hernia with Mesh Monika K Masanam, MD; Yewande R Alimi; MedStar Georgetown University Hospital The patient is a 53-year-old female who presented with 10-year history of an enlarging, painful bulge in the left lower quadrant of her abdomen. Physical examination revealed a left spigelian hernia and elective repair was planned. Pre-operatively, she was incidentally found to have a small, reducible left inguinal hernia. The patient was taken to the operating room for a robotic assisted laparoscopic spigelian hernia repair with mesh and left inguinal hernia repair with mesh. She was discharged on the day of surgery. On follow up at two weeks, patient reported well controlled pain and tolerance of a regular diet. V298 Complex Reconstruction for Gastro-Gastric Fistula after Roux-en-Y- Gastric Bypass (RYGB) Hadika Mubashir, MD1; Jerry T Dang, MD, PhD 1; Juan S. Barajas-Gamboa, MD2; Gustavo Romero-Velez, MD1; Maryam Al Zubaidi, MD1; Matthew Allemang, MD1; Salvador Navarrete, MD1; John Rodriguez, MD2; Matthew Kroh, MD1; Ricard Corcelles, MD, PhD1; 1Cleveland Clinic, Ohio; 2Cleveland Clinic, Abu Dhabi A middle-aged lady status post LRYGB, 9 months prior presented to the bariatric surgery clinic complaining of cramping abdominal pain, acidity, and failure to thrive. She had significant weight loss and had multiple comorbidities including compensating cirrhosis due to NASH. She was diagnosed to have a gastro-gastric fistula seen via EGD and UGI series and subsequently underwent the gastro-gastric fistula take down procedure. This presentation walks you through her pre, intra and post op findings following the diagnosis of the gastro-gastric fistula. V299 Robotic Extended Distal Pancreatectomy with Splenectomy for Pancreatic Adenocarcinoma Sharona Ross; Kaitlyn Crespo; Iswanto Sucandy; Alexander Rosemurgy; Digestive Health Institute Tampa This video demonstrates a robotic extended distal pancreatectomy with splenectomy for pancreatic adenocarcinoma. A 72-year-old woman presents to clinic for evaluation of a locally advanced pancreatic tail mass following extensive neoadjuvant therapy. Preoperative workup included CT scan and EUS/FNA. EUS showed decrease in tumor size and vascular involvement. Dissection and resection were undertaken without any complications and a 10-French flat JP was placed. Pathology confirmed ductal carcinoma with no nodal involvement. This video shows how a extended distal pancreatectomy with splenectomy for locally advanced pancreatic adenocarcinoma can be safely undertaken with the robotic platform. V300 Positive Air Leak, What Is Next? Andrea Hernandez Moreno1; Daniel Aillaud De Uriarte 2; Diego C Marines Copado, MD3; Victor G Peña, MD4; Roberto Secchi del Rio5; 1Universidad Anahuac Puebla, School of Medicine; 2Universidad de las Americas Puebla, School of Medicine; 3Houston Methodist Willowbrook; 4Universidad de Monterrey, School of Medicine; 5Universidad Anahuac Queretaro, School of Medicine Anastomotic leakage is a serious and feared complication in colorectal surgery, as it leads to significant mortality and morbidity. This also produces an economic burden on our healthcare system by increasing costs significantly. Air-leak testing is highly recommended during the procedure to expose mechanically insufficient colorectal anastomoses. This video is aimed to pose a safe option to deal with a positive air leak test during a robotic low anterior resection. V301 Desmoid Tumor at the Staple Line of Prior Sleeve Gastrectomy, Requiring a Laparoscopic Gastrectomy, Distal Pancreatectomy, and Splenectomy Pavel Mazirka; Jeffrey Friedman; University of Florida We present a video of a laparoscopic distal pancreatectomy, splenectomy, small bowel resection, and gastrectomy with Roux-en-Y reconstruction and hiatal hernia repair performed for a symptomatic desmoid tumor at the staple line of remote sleeve gastrectomy. Desmoids are rare benign fibroblastic tumors of mesenchymal cell origin with estimated 1000 cases in the US each year. They usually occur on the peritoneum or the mesentery, rarely being found in the stomach. To our knowledge, there is only one prior reported case of a desmoid in a stomach with prior gastrectomy. V302 Robotic Repair of a Missed Traumatic Diaphragmatic Hernia? John F Curtis, MD; Michael J Furey, DO; Charles L Cole III, MD; Alexandra M Falvo, MD; Ryan D Horsley, DO; Geisinger We present a case of a 71-year-old male who underwent laparoscopic robotic assisted repair of a missed traumatic diaphragmatic hernia 13 months after his initial trauma evaluation following a tractor roll-over. Over the course of 5 months to 1-year post-traumatic injuries, the patient experienced worsening shortness of breath and dyspnea on exertion, prompting multiple visits with pulmonology and his primary care provider. This ultimately resulted in ED presentation and emergent consultation with surgery. Repair of the traumatic diaphragmatic hernia was delayed due to failure to recognize the presence of the diaphragmatic hernia on earlier imaging studies. V303 Robot Assisted TAPP Groin Hernia Repair with 3D Mesh in a New Robotic Plat Form-Tips and Tricks Prof Subhash Khanna, MSFRCSFALSFAGIE; Swagat Super Speciality Surgical Institute We are presenting steps and technique of Robot Assisted TAPP hernia repair with 3 D mesh on a 45 years male with right sided complete inguinal hernia done on Versius Robotic platform. The dissection is done with incision of peritoneum approximately 3 cm above the anterior superior iliac spine and preperitoneal space is created. The 3D mesh 12 × 10 cm is now placed and snugly contoured to the pelvic dissected space covering the hernial opening and all potential hernial sites. The incised peritoneum is apposed with 2-0, V-Loc barbed wound closure device (Medtronic). The patient discharged in 48 h. V304 Robotic-Assisted Approach to Repairing an Epiphrenic Diverticulum Lillia Dincheva-Vogel, DO 1; Abubaker Ali, MD2; 1DMC Sinai-Grace Hospital; 2Wayne State University A 70-year-old female presented with a five-year history of dysphagia. Work up revealed a large epiphrenic diverticulum located on the ventral wall of the distal esophagus. This video demonstrates a robotic-assisted transhiatal approach to epiphrenic diverticulectomy, Heller myotomy, and Dor fundoplication. The anterior vagus nerve was sacrificed during the dissection to gain access to the epiphrenic diverticulum. Preoperatively, patient had a normal esophageal manometry study, however, a myotomy was performed to reduce the risk of diverticular recurrence or leak at the site of the staple line. V305 Robotic Cholecystectomy with Cystic Duct Choledochal Cyst Excision Clara Kit Nam Lai, MBBS; AJ Haas, MD, MMSc; Hemasat Alkhatib, MD; Angela Thelen, MD, MHPE; Kelly Zhang, MD; Alejandro Feria, MD; Sergio Bardaro, MD, FACS, FASMBS; Kevin El-Hayek, MD, FACS; Amelia Dorsey, MD; MetroHealth Medical Center Cystic duct choledochal cyst is very rare and not currently included in the Todani classification. We present a case of a 53-year-old female with history of chronic calculous cholecystitis who was referred for laparoscopic cholecystectomy. Surgery was aborted due to unexpected abnormal findings concerning for biliary neoplasm. After obtaining MRCP and referral to HPB specialist, patient underwent robotic cholecystectomy with cystic duct choledochal cyst excision. This video demonstrated the utility of robotic approach in complex biliary dissection and the liberal use of intraoperative indocyanine green cholangiography to allow safe evaluation of the biliary tree in the presence of an anomaly. V306 Abdominal Sacral Approach for Resection of Supraanal Tumours of the RECTUM—How I Do It? Raju KVVN; Pavan kumar Jonnada; Zeeba Usofi; Keshri Pradeep; Madhu Narayana; Syed Nusrath; BIACHRI This is a video demonstration of abdomino sacral approach for the resection of supra anal tumours of the lower third of rectum. This novel technique aims to achieve wider circumferential margins of the mesorectum and very useful to achieve clear margins in locally advanced distal rectal cancers in a narrow pelvis. The complications after this technique are acceptable without compromising the oncological outcomes. Hence, we describe about this procedure and describe in detail. V307 Laparoscopic Laser Lithotripsy of Difficult Biliary Stones: An Innovative Approach Noor AlNasrallah; Ali AlKhayat; Hussein Hayati; Abdullatif Al-Terki; Al-Amiri Hospital We present the case of a 55-year-old female who previously underwent mini gastric bypass weight loss surgery and laparoscopic cholecystectomy for acute cholecystitis. She presented with persistent biliary colic; MRCP revealed multiple right intrahepatic biliary stones, localized to Seg. VIII, with a strictured intrahepatic bile duct segment, and distal CBD stones, with no jaundice. Given her surgical history, we performed laparoscopic choledochotomy with laser lithotripsy using a flexible ureteroscope for both intrahepatic and CBD stones. This minimally invasive approach resulted in successful clearance of her biliary system, and a short, uncomplicated recovery course, with resolution of symptoms, avoiding major surgery. V308 Duodenoduodenostomy: a Curative Surgery for Superior Mesenteric Artery Syndrome Alana Hofmann, MD 1; Whiyie Sang, MD1; Darwin Ang, MD, PhD2; 1University of Central Florida; 2University of South Florida The duodenoduodenostomy involves complete mobilization of the midgut including ascending colon, jejunum, and ileum off the retroperitoneum to the level of the duodenum and inferior aspect of the pancreas. Once the midgut is reflected cephalad, mobilization of the duodenum is carried in its entirety. This consists of kocherization of the duodenum, takedown of ligament of Treitz, and dissection of duodenum from the inferior portion of the pancreas. The midgut is rotated clockwise with D4 folded to the right of the SMA pedicle. D3 and D4 are anastomosed to the right of the SMA pedicle. V309 Robotic excision of Gastrointestinal Stromal Tumor (GIST) and Concomitant Repair of Hiatal Hernia Edward Kim, MD, PhD; Nicole Cherng, MD; University of Massachusetts Chan medical school We present a case of a robotic excision of GIST and concomitant repair of a hiatal hernia in a 46-year-old patient with a history of GERD. His work-up revealed a pathology confirmed, 2 cm submucosal nodule at the posterior wall of the cardia of the stomach and a moderate hiatal hernia. Our video demonstrates that a small submucosal GIST can be sufficiently and safely removed via anterior gastrotomy and that other foregut operations such as hiatal hernia can be combined under single anesthesia. V310 Robotic Enucleation of Gastrointestinal Stromal Tumor with Indocyanine Green Roberto J Valera, MD; Luis F Okida, MD; Brenda Jimenez, MD; Conrad H Simpfendorfer, MD; Emanuele Lo Menzo, MD, PhD; Mayank Roy, MD; Cleveland Clinic Florida Robotic resection of gastric gastrointestinal stromal tumors (GISTs) appears oncologically safe, and can be enhanced with indocyanine green (ICG) marking. We present a case of a 51-year-old male presenting with hematemesis and syncope. Imaging showed an exophytic mass within the gastric fundus, confirmed by endoscopy. The tumor was marked preoperatively with 0.5 mL of ICG injected into each quadrant via endoscopy. The lesser sac was opened up to the fundus, and the stomach was mobilized. The tumor was identified and resected using ICG fluorescence. The gastrostomy was closed with 3–0 barbed sutures in two layers. The patient recovered uneventfully. V312 Robotic Assisted Cholecystectomy and Repair of a Cholecystoduodenal Fistula Helen H Liu, DO; David K Halpern, MD; Matthew Morris, MD; NYU Langone Hospital—Long Island Please enjoy our video of an 80-year-old female with an incidental finding and diagnosis of pneumobilia. She underwent a successful robotic repair of a cholecystoduodenal fistula with the use of intraoperative cholangiography. We demonstrate that the robotic platform is both safe and effective for surgical management of this disease process due to its associated complex findings often encountered at the time of surgery. Improved visualization, ergonomics and wristed instrumentation, combined with near infrared fluorescent imaging facilitate dissection of aberrant anatomy associated with this disease process. The utilization of the robotic platform for repair of cholecystoduodenal fistula should be considered. V314 Robotic eTEP Entry and Port Placement Jennifer A Lee, MD; Rockson Liu, MD, FACS; Alta Bates Summit Medical Center Robotic extended totally extraperitoneal (eTEP) abdominal wall repair utilizes wide dissection and extensive mesh overlap while staying out of abdominal cavity. One of the most difficult parts of this operation can be the entry, due to risk of damage to the posterior rectus sheath, injury to the linea semilunaris and entry into incorrect planes. This video demonstrates step by step techniques for entry and port placement. We highlight abdominal wall mapping, TAP and rectus sheath blocks, entry with a 5 mm laparoscope, insufflation and dissection of the retrorectus space to allow for proper port placement and docking of the robot. V315 Management of Acute Recurrent Hiatal Hernia with Perforated Nissen Fundoplication Brandon M Smith, MD; Kate Mellion, MD, FACS; Gundersen Health System The patient is a 55-year-old male who presented as a transfer from an outside facility with severe acute epigastric abdominal pain. He underwent a paraesophageal hernia repair with mesh and Nissen fundoplication 12 days prior. Work up included CT scan which demonstrated an acute recurrence of his hiatal hernia with radiographic evidence of gastric perforation. He was taken to the operating room for emergent laparoscopic reduction of incarcerated paraesophageal hernia, mesh explantation, partial gastrectomy, and gastropexy. His post-operative course and recovery were uneventful. V316 Intracolonic Lap Pad Juan Quiroz G, MD, FACS; Chendes Medical Services This video, is a spectacular case, there are many reports of surgical sponges, compress (mayor textil material) even steel instruments retained. This case began 6 months ago, male, 47 y/o, operated in other hospital lap cholescistectomy, converted to open because massive bleeding, bad posoperative evolution, increasing symptoms, his surgeon follow the posoperative. Attend to emergency room of our hospital, intestinal obstruction, evaluation included: tac, blood tests, x-ray film. required 2 days to stabilize and explored with preoperative dx of gossipiboma. Posoperative: intestinal obstruction- the comress 70 × 45 cm. eroded the wall and transmigrate into the colon producing bowel obstruction. Successful evolution. V317 Colonic Conduit Ischemia Post LAR: a Salvage Intervention Following a Rare Complication Basheer Elsolh, MD, MPH; Jeremy Huddy, BMBS, PhD; Fayez Quereshy, MD, MBA; Sami Chadi, MD, MSc; University of Toronto We review a case of a laparoscopic low anterior resection in a 50-year-old man with rectal cancer. High ligation of the inferior mesenteric artery (IMA) and full splenic flexure mobilization with inferior mesenteric vein (IMV) ligation were performed. Indocyanine green (ICG) demonstrated anastomotic limb perfusion. Recovery was initially well but he had a persistently elevated C-reactive protein (CRP) level. CT and endoscopic work-up revealed ischemia of the colonic conduit, and he was taken back to the operating room for a laparoscopic left hemicolectomy of the colonic conduit with new colorectal anastomosis and diverting loop ileostomy. His course afterwards was uncomplicated. V318 Robotic-assisted Laparoscopic Total Gastrectomy with Roux-en-Y Esophagojejunostomy and Three Small Bowel Resections for Multifocal GIST Sarah Hartman, MD; Emily Kolodka, BA; Lyudmyla Demyan, MD; Christopher Summers, PA; Sandeep Anantha, MD, FACS; Gary Deutsch, MD, MPH, FACS; Donald and Barbara School of Medicine at Hofstra/Northwell Here we present a case of a 45-year-old male with a history of Carney Stratakis syndrome who presented with severe anemia due to a suspected bleeding gastric GIST. A preoperative EUS with FNA was inconclusive and he was therefore taken to the OR to aid in both symptom control and definitive diagnosis. He underwent a robotic-assisted laparoscopic total gastrectomy with Roux en Y esophagojejunostomy and three small bowel resections for multifocal GIST. This video highlights the advantages of using a robotic approach including improved visualization and maneuverability to aid in the identification and careful removal of multiple large GISTs. V319 Robotic-assisted Hiatal Hernia Repair with Mesh and Toupet Fundoplication in a Patient with a History of Roux-en-Y Gastric Bypass Dessislava I Stefanova, MD; Genevieve Fasano, MD; Rasa Zarnegar, MD, FACS; Weill Cornell Medicine This video depicts a robotic hiatal hernia repair with mesh and toupet fundoplication utilizing the gastric remnant in a patient who had undergone a laparoscopic Roux-en-Y gastric bypass eighteen years prior. After reduction of the hiatal hernia, the alimentary limb and the gastric remnant were identified. Careful lysis of adhesions was performed to create a plane between the pouch and the remnant, as such mobilizing the remnant stomach to create a toupet fundoplication. The diaphragm appeared weak, and thus a biosynthetic mesh placed in a reverse C fashion was used to reinforce the area. V320 Endoscopic Cricopharyngomyotomy for Recurrent Zenker’s Diverticulum Monica Polcz, MD, MS; Paul Colavita, MD, FACS; Atrium Carolinas Medical Center This video demonstrates our group's routine approach for Zenkers diverticula, endoscopic cricopharyngomyotomy, in a patient with recurrent Zenker's diverticulum. We use a flexible needle knife technique with submucosal tunneling to extend the myotomy. Of note, the approach to recurrent Zenker's after prior endoscopic treatment is often facilitated by increased working space related to the prior intervention. This video details the steps to mark out and perform cricopharyngomyotomy and submucosal tunneling, as well as the anatomy of a complete myotomy. At the end of the procedure, the mucosal edges are endoscopically clipped. The patient recovered uneventfully with resolution of her symptoms. V321 Totally Laparoscopic Distal Gastrectomy: Intracorporeal Billroth II with Braun Reconstruction Kecheng Zhang; Lei Guo; Lin Chen; Canrong Lu; Department of General Surgery, Chinese PLA General Hospital First Medical Center This video shows how we perform totally laparoscopic distal gastrectomy with intracorporeal Billroth II Braun reconstruction in our daily practice. The submitted video covers the key step of this procedure. V322 Robotic-assisted Lap Band Removal, Gastro-gastric Fistula Takedown and Gastrojejunostomy Revision in a Patient with a History of Banded Gastric Bypass and Weight Regain Julia Button, MD; Amy Holstrom, MD; Gregory Dakin, MD, FACS, FASMBS; Cheguevara Afaneh, MD, FACS, FASMBS; Omar Bellorin-Marin; New York Presbyterian-Weill Cornell 56 year old female with past surgical history of open gastric bypass (2005) and lap band placed over bypass in setting of weight regain (2012) who presented to Bariatric Surgery clinic (2021) with a prolonged history of nausea/vomiting, weight regain and epigastric pain. Pre-operative upper endoscopy showed gastrogastric fistula, stenosis at gastrojejunostomy and possible band slippage. Patient went to the operating room for robotic-assisted laparoscopic lysis of adhesions, intraoperative endoscopy, lap band removal, gastrogastric fistula takedown, and gastrojejunostomy revision. Patient tolerated the procedure well without any complications and continues to do well. V323 Robotic Assisted Left Hepatectomy with Left Hepatic Duct Resection for Congenital Atresia Colleen P Nofi, DO; Lyudmyla Demyan, MD; Samantha Donovan, BS; Christopher Summers, PAC; Sandeep Anantha, MD; Gary Deutsch, MD; Northwell North Shore/Long Island Jewish Robotic approaches to hepatectomies have been on the rise owing to procedural advantages over traditional laparoscopic techniques. Here we present a case of a 42-year-old male with chronic abdominal pain, who was found to have dilated left intrahepatic ducts due to a left hepatic duct stricture without an identifiable mass. The patient underwent definitive management with complete robotic left hepatectomy with let hepatic duct resection for congenital atresia. Through this unique case, we highlight the benefits afforded by the robotic platform, including improved visualization and maneuverability to aid in complex dissection of intra- and extrahepatic inflow/outflow vessels and biliary ducts. V324 Approach to the Proximal Gastric GIST Irene Y Zhang, MD, MPH; Brant K Oelschlager, MD, FACS; University of Washington This is a case of an otherwise healthy patient undergoing laparoscopic resection of a 4 cm gastrointestinal stromal tumor (GIST) of the proximal stomach along the lesser curve. The most common technique for resecting these tumors is to use a surgical stapler, but there are important potential pitfalls of stapled resection. Here we review key oncologic and technical considerations for gastric GIST management and demonstrate a recommended resection and handsewn repair approach to preserve gastric anatomy while managing proximal gastric GISTs. V325 Robotic Ventral TAPP Repair Prashanth Sreeramoju, MD, MPH; Montefiore Medical Center This video demonstrates a robotic ventral TAPP repair for an incisional umbilical hernia. Pneumoperitoneum was achieved with a Veress needle. Xi Robot is docked on the patient's left. A circumferential preperitoneal space is dissected by scoring the peritoneum 5 cm away from the hernial defect, starting from the left. Hernial contents are reduced. The hernial defect is closed with 0 V-lock suture. A 12 cm × 12 cm soft prolene mesh was placed in the preperitoneal space centered on the closed hernia defect. Peritoneum is closed with 3–0 V-lock suture by the Connell technique. V326 Heller to Bypass: Knocking on the Dor Joseph Kuiper, MD; Caitlin Halbert, MD, FACS; Anthony Tascone, MD, FACS; Christiana Care A case of a 48 year-old female with history of hypertension, obstructive sleep apnea, BMI 37, and prior Heller myotomy with Dor fundoplication for achalasia who subsequently presented for consideration of bariatric surgery. Preoperative work-up included barium swallow, EGD, manometry, and pH testing. After a multidisciplinary meeting, she was deemed appropriate for weight loss surgery. Decision was made to proceed with robot-assisted gastric bypass with creation of the gastric pouch distal to the prior Dor fundoplication. This case was unique as a reoperation on the foregut requiring manipulation of prior anatomy. V327 Revision of Sleeve Gastrectomy to Laparoscopic Roux-en-Y Gastric Bypass for Patient with Scleroderma and Sleeve Obstruction Mary Kate Bryant, MD, MSCR; Laurel Tangalakis; Andrew S Wright, MD; Judy Y Chen-Meekin, MD; University of Washington This is the case of a patient diagnosed with scleroderma, dysphagia, and herniated sleeve with esophageal outflow obstruction several years after laparoscopic sleeve gastrectomy. We discuss the initial workup to determine the etiology of her esophageal outflow obstruction. In this case, EndoFLIP helped differentiate between achalasia and pseudoachalasia when manometry probe placement was problematic. We illustrate our surgical approach and intraoperative decision-making to address the patient's hiatal hernia and relieve sleeve obstruction with conversion to roux-en-y gastric bypass. V328 Robotic-Assisted Switch with Duodenal-Ileal Anastomosis and Sleeve Gastrectomy (SADI-S) Post Failed Roux-en-Y Gastric Bypass Rocio Castillo Larios, MD; Naga Swati Gunturu, MD; N. Busra Celik, MD; Mohammad Alomari, MD; Enrique F Elli, MD, FACS; Mayo Clinic Florida The single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is a recent modification of the BPD-DS. This procedure helps treat patients with very high BMI (> 50), with an increased risk of weight regain, or as an option for the failure of previous bariatric surgery. The SADI-S involves only one anastomosis, reducing the chances of a leak compared to other bariatric surgeries. We report the case of a 38-year-old female with a BMI of 61 kg/m2 status post Roux-en-Y Gastric Bypass. V329 Nissen Fundiplication Converted To Roux-En-Y-Gastric Bypass Russell Herberg; Katelyn Mellion; Gundersen Health System This video report has been designed to illustrate the procedure of a Nissen Fundiplication Converted to Roux-En-Y-Gastric Bypass and to demonstrate the anatomical and technical aspects therein. This particular case had extensive adhesions and required several hours of work to achieve the desired surgical outcome. V330 Adult Midgut Malrotation Victor S. Alemany, MD; Michelle Chung, MD; Katherine Donovan, MD; Zihan Dong, MD; Dimitra Lotakis, MD; Giovani Ramos, MD; Venkat Modukuru, MD; John Degliuomini, MD; Marc Wallack, MD; Metropolitan Hospital Intestinal malrotation is a congenital abnormality caused by the partial or complete failure of normal 270-degree counterclockwise rotation of the midgut around the superior mesenteric vessels in fetal life. Epidemiologically, the incidence of malrotation is about 1 in 6000 live births, with most presenting in infancy. Presentation in adults is rare. Here we present an interesting case of an adult midgut malrotation from presentation and symptomatology in the Emergency Department, diagnosis with Computed tomography imaging, and the treatment with an intraoperative video and detailed explanation of the Ladd's procedure. V331 Robotic Incarcerated Obturator Hernia Repair with Mesh Michael Danise, MD; Marcoandrea Giorgi, MD; Andrew Luhrs, MD; The Miriam Hospital We present a case of a 92 year old female who presented with right hip and thigh pain and was found with an incarcerated right obturator hernia on imaging. She was taken to the operating room and underwent a robotic obturator hernia repair. The small bowel contained in the hernia was successfully reduced and determined to be viable. A mesh based repair of the hernia defect was then performed. V332 Laparoscopic Repair of a Traumatic Diaphragmatic Rupture: A Case Report and Video Vignette Lucas Fair, MD; Jennifer Misenhimer, MD; Ryan Kostka, DO; Brittany Buckmaster, PAC; Steven Leeds, MD; Baylor University Medical Center Blunt traumatic diaphragmatic rupture is uncommon but can be a severe problem. A large impact is required to cause such an injury and it is usually seen in polytraumatized patients. Early recognition and management is imperative to optimize outcomes. Minimally invasive techniques are being increasingly utilized to manage these injuries with excellent results. We report the case of a diaphragmatic rupture in a 68-year-old female that occurred after blunt trauma. The stomach and greater omentum had herniated into the left thorax. After the organs were reduced, the diaphragmatic defect was successfully repaired using ethibond sutures with Phasix ST mesh reinforcement. V333 Closed Loop Obstruction in a Patient with Previous Kidney and Pancreas Transplant David Roberts; Olivia Haney, MD; Indraneil Mukherjee, MD, MBBS; Staten Island University Hospital A 48-year-old female with a history of DM, ESRD, HIV on HAART and simultaneous pancreas and kidney transplant in 2020 presented to the ED with one day of severe abdominal pain radiating to the lower quadrants with × 8 episodes of bilious emesis and nausea. CT showed possible closed loop bowel obstruction with tethering at a single point in the RLQ. Laparoscopy revealed grossly necrotic small bowel and one adhesive band extending from the pancreatic allograft to small bowel mesentery. 45 cm of intestine was removed followed by a coloenteric anastomosis. The patient was stable and transferred the following day. V334 Laparoscopic Appendectomy in Third Trimester Pregnancy Caleb Pflederer, MD; Michael Genz, MD; Caroline Reinke, MD; Carolinas Medical Center A 31-year-old, 34-week pregnant female presented to an outside hospital with one day of worsening right lower quadrant abdominal pain. CT scan showed evidence of appendicitis. Given the appearance of a posterior lying appendix and the anticipated difficulty of the case, she was transferred to our tertiary care hospital. She underwent an uncomplicated laparoscopic appendectomy using a right upper quadrant cutdown technique with three total assisting and working ports. Her postoperative course was uncomplicated with discharge on day three. Pathology revealed appendicitis, and she had a healthy delivery of her baby at 39 weeks. V335 Robotic Endogastric Leiomyoma Resection Jane Jaeyun Wang; Amir Ashraf Ganjouei; Fernanda Romero-Hernandez; Eric Nakakura; Mohamed Abdelgadir Adam; University of California, San Francisco This video abstract reviews a robotic endogastric leiomyoma resection technique performed for a symptomatic 8.0 × 5.3 cm leiomyoma arising from the gastroesophageal junction (GEJ). The unique aspect of this procedure includes docking the robot into the greater curvature of the stomach to endoluminally dissect the tumor from the GEJ and off the gastric serosa. This allowed for meticulous dissection of the tumor without compromising the vagus nerve, GEJ, or stomach serosa, and ultimately saved the patient from undergoing total gastrectomy. The patient was discharged on postoperative day three and continued to tolerate regular diet on the three month followup. V336 Duodenal Stricture after Ladd's Procedure: Attempted Robotic Repair Converted to Open Matthew Nester1; Sydney Korsunsky1; Joseph Sujka, MD 2; 1University of South Florida Morsani College of Medicine; 2Division of Gastrointestinal Surgery, University of South Florida We present a 21-year-old female undergoing robotic-converted-to-open lysis of adhesions and gastrojejunostomy for repair of duodenal stricture. The stricture was secondary to malrotation as a child treated with a Ladd's procedure. The duodenum extended from the right costal margin to the right anterior superior iliac spine. The operation was successful and has improved the patient's ability to tolerate oral intake. This represents a little described long term complication of the Ladd's procedure and application of the robotic platform in an attempt to correct this abnormality. V337 Robotic Assisted Enucleation of Pancreatic Neuroendocrine Tumor Chunghun Ji, MD; Daniel L Farinas, MD; Sebastian De La Fuente, MD; AdventHealth Orlando Introduction: Enucleation of pancreatic neuroendocrine tumors (PNETs) is recommended for well-differentiated neoplasms due to the low potential for lymph node positivity. MIS techniques have been employed successfully. Here, demonstrated a PNET resected from the proximal body of the pancreas. Methods: An otherwise healthy female underwent enucleation of a nonfunctional, nonmetastatic PNET robotically. Results: A well-differentiated, G1, PNET with Ki 67 index of < 1% was resected with clear pathologic margins. She had an uneventful postoperative recovery. Discussion: PNETs can be resected safely following MIS techniques if the tumor is away from vital vascular structures and pancreatic duct. V338 Step by Step Guide for a TAPP Repair of Umbilical Hernia Kryspin Mitura, MD, PhD, FACS 1; Krystian Kisielewski, MD2; Michal Romanczuk, MD2; Bernard Mitura3; Dorota Wyrzykowska2; Malgorzata Sawicka, MD2; 1Siedlce University of Natural Sciences and Humanities; 2Siedlce Hospital; 3Jagiellonian University, Collegium Medicum Neglecting the problem of these hernias may cause dramatic consequences for the patient, and require a future complex treatment. In this video we present a technique of laparoscopic TAPP technique, allowing the surgeon to dissect a large preperitoneal space, for the placement of an adequate size of a mesh, even a 6 × 6in (15 × 15 cm) mesh between posterior rectus sheath and the peritoneum. As you may see in the video, closing the defect and securing the abdominal wall with a large mesh, prevents bulging, allowing to preserve the umbilical skin, thus minimizing a risk of infection, especially in overweight and obese patients. V339 Detection of Sessile Serrated Adenoma Using Artificial Intelligence- Enhanced Endoscopy: An Asian Perspective Joycelyn Soo 1; Frederick Koh, FRCSEd2; 1Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 2Colorectal Service, Department of General Surgery, Sengkang General Hospital, SingHealth Services, Singapore Sessile serrated adenomas (SSA/P) are recognised as premalignant colorectal lesions that are crucial to detect on colonoscopy to reduce interval cancer risks. These lesions are endoscopically difficult to detect but with the aid of artificial intelligence (AI)-assisted endoscopy, real-time superimposed green boxes during colonoscopy serve as a second eye to recognise suspicious lesions. Three examples of SSA/P are described with both typical and atypical features, making comparison to a hyperplastic polyp which bear similar morphological features. This video illustration serves as an instructional guide for fellow endoscopists in the use of AI-assisted endoscopy for detection of SSA/P. V340 Sessile Serrated Lesion of the Appendix? Michael J Furey, DO; Mark E Mahan, DO; Charles L Cole III, MD; Jennifer Quinter, MS; Duane E Deivert, DO; Renee Frank, MD; Alexandra M Falvo, MD; Ryan D Horsley, DO; Geisinger Appendiceal neoplasms, usually detected incidentally by pathology following appendectomy, are relatively rare. Sessile serrated adenomas are precursor lesions to serrated adenocarcinoma. Often difficult to detect on endoscopy, they may be incompletely resected, consequently showing high rates of recurrence. We demonstrate a case of a successful appendectomy in a 72-year-old male for an abnormal appearing appendiceal orifice that was initially noted on colonoscopy. While initial biopsy results showed colonic mucosa with hyperplastic changes, given our high index of suspicion for neoplasm, our persistence for perusing appendectomy resulted in final appendix pathology showing a sessile serrated adenoma. V341 Endoscopic Removal of Gastric Band Katlin Mallette, MD; Ruxandra-Maria Bogdan; Ahmad Elnahas, MD, MSc; Nawar A Alkhamesi, MD, PhD; Christopher M Schlachta, MDCM; Jeffrey Hawel, MD, MSc; CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, and Department of Surgery, Western University, London, Canada This is a case of a 39 year old female who underwent placement of an adjustable gastric band for weight loss in 2010. During her workup for revisional bariatric surgery, she was incidentally found to have ~ 20% erosion of her band. We present here a video of removal of her eroded band utilizing endoscopic techniques under a general anesthetic. V342 Resection of Gastrointestinal Stromal Tumor Tiffany Nguyen 1; Abubaker Ali2; 1DMC Sinai Grace/ Michigan State University; 2Wayne State University Surgical resection with negative margins is the mainstay of treatment for Gastrointestinal Stromal Tumors greater than 2 cm. It has been suggested that tumors > 5 cm be resected in an open fashion as opposed to laparoscopic to avoid technical complications. Robotic assisted resection of GIST tumors have been described since 2010 as a method of resection and continue to be a feasible option. We demonstrate the process and utility of robotic resection of a 6.5 cm GIST, obtaining negative margins and without intraoprative rupture of the tumor capsule. V343 Laparoscopic Gastric Bypass Reversal Enrique Arias, MD, FACS; Irene Arévalo, MD; Otto Montoya, MD, FACS; Carlos Rodríguez, MD; Obesity El Salvador RYGB remains as Gold Standard for bariatric surgery, bypass reversal to normal anatomy has specific indications. A 57 years old female patient, 3.5 years after a RYGB, initial BMI: 38.4 kg/m2, T2D and dyslipidemia, presented mild abdominal pain and chronic diarrhea. Quality of life, and request from patient, were indications for surgery, BMI: 20.7 before reversal, diabetes and dyslipidemia remitted. Biliopancreatic and alimentary limb length was 100 cm. Technique used was gastrogastrostomy confection and Roux limb resection. Patient was discharged after 48 h without complications. 3 months after surgery patient regained weight and diarrhea episodes stopped. Current BMI 22.4 kg/m2. V344 Robotic Resection of a Primary Duodenal GIST Tristan Patel, MD; Husain Abbas, MD; Jamie Bolden, MD; HCA Orange Park Hospital A video presentation that demonstrates a rare incidental finding of a duodenal GIST that was removed via a robotic assisted resection of the 2nd, 3rd, 4th, & proximal jejunum with primary anastomosis. The video consists of a single surgery that highlights the anatomical structures associated with the proximal gastrointestinal tract, as well as the kidney and ureter. Not only will the video show an oncological resection, but will also focus on the key structures to identify when performing this type of resection. The goal of this presentation is to show a minimally invasive technique to a highly complex surgical case. V345 Gastric Bypass Reversal for the Management of Dumping Syndrome Cristhian Valor, MD; Nicole Lopez-Canizares, MD; Manish Parikh, MD, FACS; John K Saunders, MD, FACS; NYU Langone A 42 year old female with history of laparoscopic Roux-en-Y gastric bypass underwent a gastric bypass reversal in 2022 for the management of hyperinsulinemic hypoglycemia. She had been maximized on medical therapy, but ultimately underwent a laparoscopic revision with preservation of the roux limb for definitive management. She tolerated the procedure and was discharged home safely. She was noted to have decrease in symptoms at her 30-day follow up with no observed complications. Laparoscopic gastric bypass reversal is a safe and tolerable procedure that can be performed to alleviate the symptoms of hyperinsulinemic hypoglycemia, commonly referred to as dumping syndrome. V346 Remnant Stomach Obstruction After a Roux-en-Y Gastric Bypass Sherif Aly, MD; Karan Chhabra, MD, MSc; David Spector, MD; Brigham & Women's Hospital We describe a case of a 34-year-old woman who presented with persistent PO intolerance and abdominal pain 2 months after a roux-en-Y gastric bypass and a para-esophageal hernia repair. Workup included CTAP showing dilated fundus of the remnant stomach. A drain was initially placed in the dilated remnant fundus with partial improvement of symptoms. A drain study showed minimal contrast transit from the proximal remnant stomach to the distal remnant stomach. She was taken to the operating room for a diagnostic laparoscopy with plans for gastric fundal resection of the remnant stomach. Her symptoms improved post-operatively. V347 Laparoscopic Band Removal with Transgastric Gastrorrhaphy for Gastric Outlet Obstruction after Vertical Banded Gastroplasty Saeed Arefanian; Andrew Wheeler; University of Missouri—Columbia Gastric outflow obstruction is a known complication after vertical banded gastroplasty. Chronic strictures are often not amenable to dilation in this context due to presence of the band foreign body. Conversion to gastric bypass is a viable option that allows additional weight loss if the patient still suffers from obesity. However, gastric bypass has known potential complications and side-effects. In patients not desiring gastric bypass, laparoscopic band removal with widening of the outlet is one option. We present a case of laparoscopic band removal with transgastric gastrorrhaphy to widen the outlet for chronic gastric outflow obstruction after vertical banded gastroplasty. V348 Robotic Completely Intracorporeal Anastomosis Technique in Left Colonic and Rectal Surgery Andrew M O'Neill, MD; Christine Holloway, MD; Henry J Lujan, MD; Jackson South Medical Center As robotic techniques in colorectal surgery become increasingly popular, we are continuing to describe new and innovative techniques for creation of the colorectal anastomosis. This video compares intracorporeal versus extracorporeal techniques and shows creation of a robotic completely intracorporeal end-to-end anastomosis. The advantages of the completely intracorporeal technique are described including faster operative time, better extraction site, lower hernias, and decreased traction injury. Given its advantages we believe intracorporeal anastomosis in the appropriate setting should be the standard approach for all robotic left sided colorectal surgeries. V349 Robotic Conversion of Gastric Sleeve to Roux-en-Y Gastric Bypass Requiring Subsequent Laparoscopic Distalization for Persistent GERD Daniel Tomey, MD1; Alessandro Martinino, MD2; Roberto Secchi del Rio, MD 3; Yoon Kyung Lee, MD1; Rodolfo J Oviedo, MD, FACS, FASMBS, FICS1; 1Houston Methodist Hospital, Houston, TX, USA; 2Faculty of Medicine and Surgery, Sapienza University of Rome, Rome, Italy; 3Universidad Anahuac Queretaro, School of Medicine, Santiago de Queretaro, Mexico A 42-year-old woman underwent a robotic conversion of gastric sleeve (GS) to Roux-en-Y bypass (RYGB) requiring subsequent laparoscopic distalization. She was diagnosed with severe Gastro-Esophageal Reflux (GERD) disease after her laparoscopic GS procedure. The patient was followed up for 6 months, with appropriate weight loss, but with persistent GERD. A decision was made to perform a revisional surgery with laparoscopic distalization of the RYGB. This consisted of a new jejunojejunostomy anastomosis with a 150 cm alimentary limb creation to treat the reflux symptomatology while improving diversion of biliary fluids. The patient was followed for 1 year without incidence of GERD. V350 Demonstration of Robotic Roux-en-Y Gastric Bypass with Concurrent Giant Paraesophageal Hernia Repair Christopher B Le, MD; William Hope, MD; Amelia Lucisano, MD, MS; Bestoun Ahmed, MD, FACS, FRCS, FASMBS, ABOM; UPMC An increasing number of individuals are seeking bariatric surgery as a means for durable weight loss following failure of non-surgical means. With the increasing adoption of robotic technology in surgery as a whole, the use in bariatric surgery is increasing as well. This is a video presentation of a robotic Roux-en-Y gastric bypass for the treatment of morbid obesity completed concurrently with repair of a large paraesophageal hernia. We wish to highlight the advantages of the robotic platform in an obese patient with a PEH, including improved transhiatal visualization along with lessened surgeon fatigue during a longer case. V351 Robotic-assisted Cholecystectomy in Abdominal Situs Inversus Julie Clanahan, MD; Ariana Naaseh, MD; Victoria Gershuni, MD, MSGM, MTR; Michael Awad, MD, PhD; Washington University in St. Louis Pure laparoscopic approaches to cholecystectomy in patients with situs inversus have been previously described. These rare cases can be more technically challenging given reorientation to the left upper quadrant and potential difficulty skeletonizing key structures in the hepatocystic triangle. In this case, we demonstrated the use of robotic assistance as a safe alternative to introduce benefits of increased bimanual dexterity and improved surgeon ergonomics when approaching cholecystectomy in patients with aberrant anatomy. Further, we recommend the routine use of intra-operative cholangiogram in these patients to detect and avoid injury to possible aberrant ductal anatomy. V352 Da Vinci Robotic Surgery Revision of Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass Yara B Samman, MS 1; Samuel Guba, MD2; Sarah Samreen, MD, FACS1; 1The University of Texas Medical Branch John Sealy School of Medicine; 2The University of Texas Medical Branch Department of Surgery Vertical Banded Gastroplasty was once a very common bariatric procedure done for weight loss 2 to 3 decades ago. However, this procedure has been mostly abandoned due to the long term unsatisfactory results such as significant weight re-gain and complications such as food bolus outlet obstruction, reflux, hiatal hernias, staple line disruption, and silastic band erosion. Since VBG operations were performed as open surgeries, revision of the surgery has its own complications. In this video we show our 12 step process for the minimally invasive revision of VBG to Roux-en Y gastric bypass using the Da Vinci robot. V353 Robotic-assisted Obturator Hernia Repair Lorna A Evans, MD; Federico J Serrot, MD, FACS, FASMBS; Felipe Maegawa, MD, FACS; Dipan Patel, MD, FACS; Jamil Stetler, MD, FACS, FASMBS; Ankit D Patel, MD, FACS, FASMBS; Emory We present a 57-year-old female, with a medical history of left groin pain and left leg pain for a year. She was having difficulty walking and lifting more than 10 pounds. Physical exam was normal. Workup which included an MRI showed 2.6 × 2.1 cm left fat containing obturator hernia. She was referred to us for a minimally invasive repair. V355 Robotic-assisted Hiatal Hernia Repair, Candy Cane Excision, Partial Remnant Gastrectomy and Closure of Internal Hernia on a Patient with Chronic Pain After Roux en Y Gastric Bypass Julia Button, MD; Amy Holstrom, MD; Gregory Dakin, MD, FACS, FASMBS; Cheguevara Afaneh, MD, FACS, FASMBS; Omar Bellorin-Marin, MD, FACS, FASMBS; New York Presbyterian-Weill Cornell 57-year-old female with previous gastric bypass in 2007 presented to clinic with epigastric pain that radiated to left side worsened with eating in addition to frequent nausea. Pre-operative esophagogastroduodenoscopy revealed a long candy cane limb and a hiatal hernia. Patient underwent robotic-assisted hiatal hernia repair and candy cane limb excision. Intra-operatively patient was noted to have an unusual configuration of the remnant stomach and a mesenteric defect at which point it was decided to pursue partial remnant gastrectomy and internal hernia closure. Patient did well and was discharged on a clear liquid diet on post-operative day 1. V356 Laparoscopic Totally Extraperitoneal Repair of an Incarcerated Femoral Hernia Amelia C Lucisano, MD, MS; Christopher Le, MD; William Hope, MD; Douglas Reed, MD; Bestoun Ahmed, MD, FACS, FRCS, FASMBS, ABOM; UPMC While femoral hernia are less common than inguinal hernia, they are associated with higher morbidity and thus warrant repair. Our video demonstrates the case of a symptomatic femoral hernia containing incarcerated fat, and repair using a laparoscopic totally extraperitoneal approach. Given the large size of the hernia, the inguinal ligament was carefully incised from the posterior/extraperitoneal approach, allowing full reduction of the hernia contents. Mesh was placed to cover all the groin hernia spaces. The patient had an uneventful recovery. V357 Gastric Lymphoma in a Large Gastric Perforation on a Patient with Dental Abscess Laparoscopic Partial Gastrectomy with Billroth II Reconstruction Lorna Evans, MD 1; Jamil Stetler, MD, FACS, FASMBS2; Ankit Patel, MD, FACS, FASMBS2; Felipe Maegawa, MD, FACS2; Elizabeth Hechenbleikner, MD, FACS, FASMBS2; Mobola Oyefule, MD2; Scott Davis Jr, MD, FACS, FASMBS2; Edward Lin, MD, FACS, FASMBS2; Federico Serrot, MD, FACS, FASMBS2; 1Universidad de Buenos Aires; 2Emory University This is the case of a 74 year old male with 6-day h/o dental abscess. Being treated with PO antibiotics and Ibuprofen 2400 mg daily until oral surgery scheduled for a week later. In the ER complains of progressive inability to open his mouth and recent abdominal pain. ENT consulted for oral abscess. General Surgery consulted for abdominal pain with associated pneumoperitoneum on CXR and Abdominal CT Scan. This video presents a laparoscopic subtotal gastrectomy on a patient with a large (4 × 4) posterior gastric perforation with Billroth II reconstruction. Final pathology showed Gastric B cell lymphoma (MALTOMA). V358 Robotic Assisted Redo Heller Myotomy for Achalasia, Posterior Approach with Inadvertent Esophageal Perforation and Repair Jesus Garcia; Jacob Meariman; Louisiana State University Video demonstrates posterior approach of Heller cardiomyotomy for recurrent Achalasia, and repair of inadvertent esophagotomy. 56 yo female with recurrent dysphagia. hx of achalasia and laparoscopic anterior Heller myotomy and Dor fundoplication. In surgery, while taking down Dor, esophagotomy was inadvertently created along the previous anterior esophagotomy. Immediately recognized and confirmed endoscopically. Scope was the used to guide our dissection. Esophagus was mobilized and posterior myotomy was performed. Esophagocardiomyotomy was performed with hook electrocautery on the posterior esophagus and cardia. Esophagotomy was closed primarily. EGD ruled out leak or stenosis. Fundoplication was recreated and drain placed. Non complicated postoperative course. V359 Extended Totally Extraperitoneal Repair of Bilateral Spigelian and Ventral Hernias with Bilateral Rectus Fascia and Transversus Abdominis Advancement Flaps Charles A Baldi, MD 1; Marcoandrea Giorgi, MD2; 1Rhode Island Hospital/Brown University; 2Brown Surgical Associates A totally extraperitoneal repair and transversus abdominis release in a 76 year-old male with a ventral hernia and bilateral Spigelian hernias is shown. This technique is used in order to allow for minimally invasive retrorectus placement of mesh, which has been suggested to have advantages including fewer surgical site complications and recurrences. Using an optical access trocar, the retrorectus space is accessed and isolated for mesh placement. The dissection of the retrorectus space with robot assistance as well as reduction of three hernias and placement of mesh is shown. A transversus abdominis release was necessary to achieve adequate mesh overlap. V360 Laparoscopic Management for Small Bowel Obstruction Caused by Mesodiverticular Band Nathawadi Techalertsuwan, MD; Voraboot Taweerutchana, MD; Siriraj Hospital Mesodiverticular band (MDB) is a rare congenital intestinal malformation which can cause bowel obstruction. Only two case reports were managed by laparoscopy. Retrospective data supported the better postoperative outcomes in laparoscopic surgery. We presented a patient who was diagnosed with this condition and was successfully treated by totally laparoscopic approach. The patient did not have any perioperative complication and could be discharged home uneventfully on postoperative day 3. V361 Laparoscopic Veress Assisted Two Port Appendectomy (VATPA)—An Innovative Time Saving Technique Tayyab Riaz, FCPS, Surgery; ABWA Hospital & Research Centre Laparoscopic Veress Assisted Two Port Appendectomy (VATPA) is an innovative time saving technique of doing reduced port appendectomy with the help of veress needle, using Loop Passer and 2 mm Knot pusher. In the beginning of this video, self-made loop passer and 2 mm knot pusher are described and the detailed procedure along with technical aspects demonstrated in rest of the video. This technique has many benefits, the biggest one being time efficiency. Others include cosmetically favorable outcomes and cost-effectiveness as compared to SILS. After doing almost 20 such procedures, I never encountered any veress related complications. V362 Difficult Cholecystectomy with Cholecystogastric Fistula Ali Safar; Atif Jastaniah; McGill University Laparoscopic cholecystectomy is one of the most common general surgery operations, and cholecystogastric fistula is a rare complication of gallstones that may be encountered intraoperatively. We present a case of cholecystogastric fistula that was unexpectedly found during elective laparoscopic cholecystectomy in a 61 year old female. The patient presented with a clinical picture of chronic cholecystitis. Her abdomen was mildly tender in the right upper quadrant. She had a normal white count with normal total bilirubin. Ultrasound showed cholelithiasis with gallbladder distension. She underwent laparoscopic cholecystectomy with repair of the cholecystogastric fistula and application of an omental patch. Postoperative course was uneventful. V363 Duodenal Switch to Gastric Bypass Revision Quinn P Losefsky 1; Rohan Jeyarajah, MD2; 1Burnett School of Medicine at TCU; 2Methodist Richardson Medical Center Here we present a revision of a biliopancreatic duodenal switch to a Roux-en-Y gastric bypass using an Xi DaVinci robot. The patient had presented with severe gastroesophageal reflux. She had an excellent outcome post-operatively and has had complete resolution of her symptoms. V364 Laparoscopic Left Adrenalectomy for Conn's Tumor Briana Leung; Matthew Jacobsson; Erik Domas; Eugene Cho; St. Joseph Medical Center Laparoscopic adrenalectomy has been reported to be more technically challenging in obese patients. Previous studies have identified obesity as a risk factor for increased postoperative complications and morbidity. This is a case of a 64-year-old obese man (BMI 36) with biochemical evidence of Conn's syndrome and a 1.5 cm left adrenal adenoma. A laparoscopic lateral transabdominal approach remains a safe and feasible approach in morbidly obese patients, with minimal blood loss and short hospital length-of-stay. V365 Morgagni Hernia in An Adult Patient: A Rare Case of Complex Laparoscopic Management Marwa B Alhalawani, MD; Juan S Barajas-Gamboa, MD; Mohammed Abdallah, MD; Gabriel Diaz Del Gobbo, MD; Javed Raza, MD; Carlos Abril, MD, PhD; Juan Pablo Pantoja, MD; John Rodriguez, MD; Cleveland Clinic Abu Dhabi A 27-year-old male, with no past medical or surgical history, presented with epigastric pain, reflux and heartburn of 6 months duration. CT scan showed a broad 10 × 10 cm2 diaphragmatic hernia. Laparoscopically, General inspection revealed large anterior diaphragmatic hernia (MH), with transverse colon, small bowel and omentum with part of liver herniated through it. Hernia contents were reduced, and then the sac of hernia was dissected from the diaphragm and separated from the left pleura. The defect was closed primarily and with a composite polyester mesh. Patient tolerated the procedure well and was discharged post-operative day 3. V367 A case of Recurrent Duodenal Ulcer Treated with Endoluminal Wound Vac Therapy and Robotic Highly Selective Vagotomy Jenny Zhang; Andrew Luhrs; Marcoandrea Giorgi; Warren Alpert Medical School of Brown University A 59-year-old male with a history of perforated duodenal ulcer requiring open graham patch repair presented to our hospital with recurrent, contained duodenal perforation. We initially managed it with endoluminal wound vac therapy. After three exchanges, the ulcer appeared smaller and clean. However, the patient continued to smoke and was noncompliant with medications. He presented again with contained duodenal perforation, and we proceeded with a robotic highly selective vagotomy. We were able to divide the terminal branches of the anterior and posterior vagus nerves, including the criminal nerve of Grassi. On follow up, the patient reported recovering well. V368 Laparoscopic Splenectomy for COVID-19-induced Autoimmune Hemolytic Anemia Stephanie Chan, BS1; Elizabeth W Tindal 2; Andrew R Luhrs, MD3; 1Warren Alpert Medical School of Brown University; 2Brown/Rhode Island Hospital; 3Brown/The Miriam Hospital This video depicts a laparoscopic splenectomy which was performed in order to address problematic sequelae of COVID-19. The patient in this unique case is a 60-year-old female with a history of a past COVID-19 infection which resulted in severe autoimmune hemolytic anemia. Despite maximal medical therapy, she has remained symptomatic, requiring hospitalizations and numerous blood transfusions. As a result, she was taken to the operating room for a laparoscopic splenectomy. She had mild splenomegaly but the procedure proceeded without complication. She was able to return home on post-operative day one and has required no further steroids or blood products since. V369 Laparoscopic Extended Right Hemicolectomy for Perforated Colon Cancer Debolina Banerjee, MD; Marcoandrea Giorgi, MD; Rhode Island Hospital/Brown University This video describes the case of a fifty-nine year-old female with perforated colon cancer at the hepatic flexure who underwent an emergent laparoscopic extended right hemicolectomy. A medial-to-lateral approach was used to mobilize the right colon. High ligation of ileocolic, right colic, and middle colic vessels was completed. The terminal ileum was divided 5 cm proximal to the cecum. A similar margin of normal-appearing tissue was ensured at the distal extent of resection in the mid-transverse colon. A side-to-side functional end-to-end intracorporeal ileocolic anastomosis was completed. Pathology subsequently demonstrated pT3N2a cancer and negative surgical margins, for which this operation was curative. V370 Laparoscopic Roux-en-Y Gastric Bypass: Totally Stapled Technique with Circular Stapler Justin L Hsu, MD; Timothy Farrell, MD, FACS; University of North Carolina at Chapel Hill Gastric bypass has been an enduring bariatric procedure ever since it was first conceptualized by Edward Mason in 1966. Its subsequent development into the Roux-en-Y gastric bypass in 1977 by Ward Griffen and the first laparoscopic approach reported in 1994 by Alan Wittgrove served to continue its legacy as a procedure that stood the test of time. One of the most variable portion of the procedure involves the gastrojejunostomy and several techniques have been described. We present a totally stapled technique with a circular stapler that facilitates trainee involvement and has been practiced here for over 20 years. V371 Bilateral Recurrent Laryngeal Nerve Lymph Node Dissection in Minimally Invasive Oesophagectomy Aung Myint OO, MD, FRCSEd, FACS 1; Kon Voi Tay, MD, FRCSEd2; Prashant Shrirang Dhanke, MD2; 1Tan Tock Seng Hospital, Singapore; 2Woodlands Health Campus, Singapore Tan Tock Seng Hospital is Singapore's second largest acute care general hospital with over 1500 beds. It is a training hospital for both undergraduates and postgraduates. Minimally Invasive surgery becomes more and more popular nowadays. In our department, all the residents and fellows have to view the important steps in the instructional videos of minimally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. This is the video of bilateral recurrent laryngeal nerve lymph node dissection in minimally invasive oesophagectomy. V372 Laparoscopic Hepaticojejunostomy Revision for a Benign Stricture Jared A Forrester, MD 1; Jon M Gerry, MD2; 1Portland Providence Cancer Institute; 2The Oregon Clinic Center for Advanced Surgery Division Our video illustrates a laparoscopic hepaticojejunostomy revision for a benign anastomotic stricture. The patient underwent a laparoscopic pancreaticoduodenectomy 2.5 years ago for pancreas adenocarcinoma with completion of adjuvant chemotherapy and no evidence of disease. She had elevation in liver function tests with MRI imaging showing intrahepatic biliary ductal dilation with transition point at the anastomosis. The stricture was investigated both endoscopically and percutaneously with no evidence of malignancy. Herein, we describe our surgical approach and technique for performing a laparoscopic isolation of the anastomosis with dissection of the overlying right hepatic artery, resection of the stricture, and intracorporeal anastomosis. V373 Toupet Fundoplication After Gastric Bypass Christopher J Zimmermann 1; Zachary Callahan, MD1; Julia Amundson, MD2; Mason Hedberg, MD1; Michael Ujiki, MD1; 1NorthShore HealthSystem; 2University of Chicago This is a video demonstration of a Toupet fundoplication performed for persistent symptomatic acid reflux disease in a patient with a prior Roux en-Y gastric bypass performed for heartburn and chronic cough recalcitrant to proton pump inhibitors. Patient positioning and port placement are discussed, as are the important operative steps: lysis of adhesions, mobilization of the fundus, hiatal dissection with repair of any hiatal hernia, cruroplasty, and fundoplication. V374 Robotic Conversion of Endoscopic Gastrojejunostomy to Subtotal Gastrectomy with Roux-en-Y Reconstruction in Patient with Gastroparesis Vikrom K Dhar, MD; Omar Bellorin, MD; Srihari Mahadev, MD; Gregory Dakin, MD; Cheguevara Afaneh, MD; New York Presbyterian Hospital—Weill Cornell Medical Center In this video, we present a 64 year old woman with long-standing history of diabetes and gastroparesis who had previously undergone multiple endoscopic interventions including gastric per oral endoscopic myotomy (G-POEM) and endoscopic ultrasound-guided gastrojejunostomy with lumen apposing stent. Despite these interventions, she continued to experience issues with gastric emptying and symptoms of poor oral intake and malnutrition. Here, we present the anatomy and operative approach to converting previous endoscopic gastrojejunostomy to subtotal gastrectomy with Roux-en-Y reconstruction. V376 Robotic Cholecystectomy with Variant Biliary Anatomy Jenny MacDowell, MD; Mike Passeri, MD; Valley Hospital This is a case of variant biliary anatomy identified intraoperatively using indocyanine green cholangiography during robotic cholecystectomy. The patient had a subvesical duct, also known as a Duct of Luschka, that was identified and clipped prior to transection. Due to their small size, these ducts often go unnoticed and are prone to injury that can lead to a postoperative bile leak. In our case, we were able to identify the subvesical duct prior to iatrogenic injury given the improved visibility of the robotic platform and the use of indocyanine green cholangiography. V378 Robotic-assisted Traumatic Diaphragmatic Hernia Repair Sarah M Felleman, BA 1; Aditya Das, MD2; Quynh Lam, MD2; Robert K Josloff, MD2; 1Thomas Jefferson University; 2Jefferson Abington Hospital We present a case of robotic-assisted traumatic diaphragmatic hernia repair. A 79-year-old woman presented with severe epigastric pain. Her past medical history was significant for a fall years ago with resultant left rib fractures. CT scan revealed a defect in the left diaphragm with the stomach incarcerated within the hemithorax. The da Vinci Xi robotic system was used via a transabdominal approach to reduce the hernia contents into the abdominal cavity. da Vinci's Firefly™ feature was utilized with injection of indocyanine green to confirm the viability of the stomach. The defect was then closed primarily with Stratafix™ suture. V380 Management of Mucosal Tear During Laparoscopic Heller Myotomy Abby C Larson, MD 1; Douglas S Smink, MD, MPH2; David Spector, MD2; 1Brigham and Women's Hospital; 2Brigham and Women's Faulkner Hospital The patient is a 50-year-old female diagnosed with severe longstanding type I achalasia. Preoperative plan was to perform a laparoscopic Heller myotomy with Toupet fundoplication. As we extended the myotomy to the proximal stomach, a mucosal tear was created. This was repaired primarily with 2–0 absorbable sutures. We changed our preoperative plan and performed a Dor fundoplication to buttress the mucosal repair. Esophagogastroduodenoscopy under saline was negative for leak. The patient did well postoperatively with a normal esophagram. She is now tolerating a regular diet without reflux. This case demonstrates effective management of a mucosal tear during Heller myotomy. V381 First Non-Bariatric Use of a 230 mm Stapler for Partial Gastrectomy of a Dieulafoy Lesion Causing Life-Threatening Hemorrhage Caitlin Galbo, MD; Brian R Quaranto, MD; Salini Hota, MD; Aaron Hoffman, MD; SUNY at Buffalo Department of Surgery We present a video abstract demonstrating the technique employed during the first known use of a 230 mm stapler for a non-bariatric indication to perform partial gastrectomy of a Dieulafoy lesion causing life-threatening hemorrhage. The patient is a 60 year old female that developed upper GI hemorrhage that had failed multiple endoscopic and catheter-directed interventions. This technique minimized operative and anesthesia time in a critically ill patient, and facilitated an anatomically superior resection with a single staple firing. V382 Laparoscopic Treatment of a Super Big Type 4 Paraesophageal Hernia Benjamin Clapp, MD; Texas Tech HSC Paul Foster School of Medicine This video highlights the laparoscopic approach to a very large hiatal hernia. The video includes the reduction of the hernia contents and the diaphragmatic hernia repair. It highlights the technical aspects of a tough hernia reduction. Pre and post operative images are provided. V383 Laparoscopic Median Arcuate Ligament Release: A Unique Challenge Sohni Singh, MD 1; Christina Kim, MD2; Harminder Sandhu, MD1; Abdul Waheed, MD1; Margaret Gonikman, MS3; Kevin Yu, MS4; Steven Maximus, MD2; Victoria Lyo, MD2; 1San Joaquin General Hospital; 2University of California Davis Medical Center; 3St. Georg's University, School of Medicine; 4California Northstate University College of Medicine. Median Arcuate ligament release 20-Year-Old Female with three years of debilitating epigastric postprandial abdominal pain associated with 20 Ibs of weight loss. The patient underwent extensive gastroenterology workup, which was negative. The patient was referred to vascular surgery and MIS collaboration. Duplex U/S was performed, demonstrating abnormal velocity at the proximal celiac artery. MR angiogram revealed narrowing and hooked figuration of the celiac artery with mild post stenotic dilation. The imaging was consistent with medical arcuate ligament syndrome, and patient underwent laparoscopic surgery. V384 Laparoscopic Sleeve Gastrectomy in a Patient with Dextrogastria Ariana Metchik, MD1; Janeth R Campbell, MS2; William S Azar, MS2; Noosha Deravi1; Maya Jackson, MD1; Yewande R Alimi, MD1; Ivanesa Pardo, MD, FACS, FASMBS 1; 1MedStar Georgetown University Hospital and Washington Hospital Center; 2Georgetown Medical School We present a rare case of dextrogastria encountered during an elective laparoscopic sleeve gastrectomy in a 20-year-old woman with hypertension and morbid obesity. Preoperative endoscopy was normal except a small hiatal hernia. Intraoperatively, the stomach was notably absent from the left upper quadrant. After intraoperative endoscopy and inspection of the surgical field, the stomach and multiple spleens were found in the right upper quadrant deep to the liver, consistent with a rare variant of dextrogastria (situs inversus of the stomach) which already has an incidence of < 1:100,000. After appropriately identifying anatomy, we proceeded with the planned procedure. V385 eTEP: A Standardized Approach Masoud S Chopan, Advanced GI MIS Robotics Fellow; Emmanuel Lefontaine Mejias, Transition toPractice MIS Fellow; Jack L Fitzsimmons, Student Researcher; Rockson Liu, MD, PI; Sutter Alta Bates Summit Medical Center We demonstrate our approach to eTEP ventral hernia repair utilizing Davinci Xi Robotic Platform and standardized the steps of our operation so that it can be recreated by others. V386 Robotic Assisted Partial gastrectomy and Right Colectomy via Single Dock Supra-Pubic Approach Rahila Essani, MD, FACS, FASCRS; Monique Hassan, MD, MBA, FASMBS, DABOM; Baylor Scott and White Health This video demonstrates Single dock suprapubic approach for two organ system multi-quadrant surgery performed simultaneously. The patient underwent partial Gastrectomy and Right hemicolectomy for a 6 cm Gastric GIST and cecal adenocarcinoma. The final pathology demonstrated low grade GIST and moderately differentiated cecal adenocarcinoma with T3N1a (1/14). He was started on full liquid diet post-operatively and was discharged home POD#3. V387 Left Hepatic Duct and Portal Vein Branch Injuries During Robotic Partial Hepatectomy for Biliary Cystadenoma Stephanie Young, MD, MPH 1; Christina K Tse, MD2; Patrick D Lorimer, MD1; Ronald F Wolf, MD, FACS2; 1Saint John's Cancer Institute; 2University of California Irvine We present a 55-year-old female with a large mucinous cystic neoplasm in hepatic segments 4a, 4b, 5, and 8. She underwent formal resection of the biliary cystadenoma with robotic-assisted laparoscopic partial hepatectomy and intraoperative ultrasound, Navgino classification H45′8'. Preoperative imaging noted abutment of bilateral portal pedicles due to the central nature of the cyst. This video illustrates both the complications and repairs of a left hepatic duct injury and portal vein branch injury, and highlights basic surgical techniques such as the Pringle maneuver, suture ligation, and use of hemostatic agents. V388 Optimizing the Robotic Left Colectomy to preserve the Mesenteric Inferior Vein Luis Romagnolo, MD 1; Felipe Diniz, MD2; Carlos Veo, MD, MsC, PhD2; Rodrigo Bregeiro, MD2; Marcos Denadai, MD, MsC, PhD2; Armando Melani, MD, MsC1; 1Barretos Cancer Hospital / Ircad América Latina; 2Barretos Cancer Hospital Here, we present a left colectomy using a Robotic Plataform DaVinci Si and preserving the inferior mesenteric vein as a model to try to increase the drainage venous. We take the Left branch of IMA first and we keep all the vein tract and performing a intracorporeal anastomose using a double layer suture. The patient had not complications and was discharged after 3 days with no occurr of complains. V389 Laparoscopic Resection of a Recurrent Celiac Ganglioneuroma Jennifer L Leiting, MD; Susanne G Warner, MD; Michael L Kendrick, MD; Mayo Clinic Our patient was a 33-year-old female who presented with abdominal pain and nausea. Patient had a history of an abdominal ganglioneuroma that was resected laparoscopically in 2017. Cross sectional imaging showed a recurrence. Patient was brought to the operating room for a laparoscopic resection. The lesion was densely adherent to the common hepatic artery and a replaced right hepatic artery. The nerve sheaths of the common hepatic artery and celiac axis were mobilized with the mass for a maximal margin. Small feeding vessels were clipped and divided. The specimen was removed in its entirety. V390 Laparoscopic Bochdalek Hernia Repair Maryam Al Zubaidi, MD1; Juan Barajas-Gamboa, MD2; Jerry Dang, MD, PhD 1; Hadika Mubashir, MD1; Matthew Kroh, MD1; Carlos Abril, MD2; Ricard Corcelles, MD1; 1Cleveland Clinic; 2Cleveland Clinic Abu Dhabi We are presenting a case of Bochdalek hernia in 50 years old male. Which is a rare presentation in adult. Laproscopic management through abdominal approach was safe and successful. V391 Distalization Reversal for Treatment of Chronic Malnutrition Elizabeth Santone, MD; Abdelrahman Nimeri, MD, FACS, FASMBS; Atrium Health This video presents successful revision of roux-en-y gastric bypass distalization procedure complicated by short common channel and subsequent protein calorie malnutrition. The patient underwent roux-en-y gastric bypass in 2001. She then underwent type 1 distalization in 2015 for weight regain. Afterwards, she developed diarrhea and malnutrition requiring total parenteral nutrition. During laparoscopic evaluation, her common channel measured only 85 cm and she had an internal hernia at the distal anastomosis. This hernia compromised blood supply to the anastomosis requiring creation of a new ileoileostomy. The revision was otherwise completed without issue and the patient has since clinically improved. V392 Identification and Resection of an Incidentally Found Small Bowel Tumor During a Robotic Assisted Roux-en-Y Gastric Bypass Genevieve Gill-Wiehl, MD, MPH; Brittany Mead, MD; Scott Schimpke, MD; Rush University Medical Center This case report highlights a rare small bowel tumor incidentally found during a robotic assisted roux-en-y gastric bypass surgery for morbid obesity. The tumor was identified approximately 60 cm distal to the ligament of treitz. The involved segment of small bowel was resected and sent for pathology. The rest of the gastric bypass was completed in the standard fashion. The pathology ultimately demonstrated a high grade gastrointestinal stromal tumor (GIST) with negative margins. The patient was referred to medical oncology for further evaluation and the patient was started on a planned 3 year treatment protocol with adjuvant imatinib. V393 Minimally Invasive Esophagectomy with Lymphadenectomy in Prone Position Raju KVVN; Pavan Kumar Jonnada; Pradeep Keshri; Madu Narayana; Syed Nusrath; Sri Siddartha Nekkanti; BIACHRI This is a video demonstration of minimally invasive esophagectomy with lymphadenectomy for midlle third esophageal cancer This novel technique aims to achieve wider circumferential margins of the mesoesophagus, decreases hospital stay and morbidity. The complications after this technique are acceptable without compromising the oncological outcomes. Hence, we describe about this procedure and descibe in detail. V394 Laparoscopic Peritoneal Lavage for Biliary Ascites in Post-cholecystectomy Delayed Cystic Duct Stump Leak Aditya Kumar; Sambit Kar; Nikhil Gupta; Arun K Gupta; ABVIMS & Dr RML Hospital Cystic duct stump leaks are rarely seen post laparoscopic cholecystectomy for symptomatic gall stone disease. The incidence has been estimated to be approximately 0.42–1.1%. When recognized early, endoscopic stenting usually suffices. However, when diagnosis is delayed, biliary ascites/peritonitis ensues. Endoscopic manoeuvres are usually insufficient and often require laparotomy leading to longer hospitalization and higher morbidity and mortality. Laparoscopic lavage may be an helpful alternative in delayed biliary ascites/peritonitis, which has conventionally been considered unsafe. We present our video on the role of laparoscopic lavage in a patient where cystic duct stump leak occurred late and presented with gross biliary ascites. V395 Single Dock Robotic Ventral and Bilateral Inguinal Hernia Repair Kevin Janek, MD; Ryan Juza, MD; University of Wisconsin The robotic extraperitoneal approach for ventral hernia reconstruction has enabled complex abdominal wall reconstructive techniques with minimal incisions. Using a single dock and left-sided instrument placement, we performed a total extraperitoneal abdominal wall reconstruction with bilateral myofascial advancement flaps and bilateral inguinal hernia repair for a patient with an incarcerated incisional hernia and concurrent bilateral inguinal hernias. The patient was discharged home on post-operative day 1 after an uneventful recovery. V396 Laparoscopic Conversion of Mini-bypass to Roux-en-Y Gastric Bypass for Severe Reflux John W Keyloun, MD1; Mai Al-Khadem, MD 1; Ivanesa Pardo, MD, FACS, FASMBS2; 1Medstar Georgetown University Hospital; 2Medstar Washington Hospital Center The one-anastomosis (mini) gastric bypass has been gaining widespread popularity amongst bariatric surgeons. It consists of a long gastric pouch and a loop gastrojejunostomy. Its advantage over the Roux-en-Y is the presence of a single anastomosis. It is associated with a shorter operative time and excellent weight loss outcomes. Unfortunately, a predominant complication of the OAGB is bile reflux with consequent esophageal and gastric cancers. Patients can be symptomatic enough that the procedure needs to be revised. In this video, we present a patient with a laparoscopic conversion of a mini-bypass to Roux-en-Y gastric bypass for severe reflux. V397 Lap Transgastric Necrosectomy: Step Out—To a New Paradigm Jonathan C DeLong, MD; Rejoice F Ngongoni, MD; Hester C Timmerhuis, MD; Cintia Kimura, MD; David I Hindin, MD; Brooke Gurland; Monica M Dua, MD; Brendan C Visser, MD; Stanford The Step-Up approach is the current standard of care for management of infected necrosis for necrotizing pancreatitis. However, recent advancements in surgical and procedural management of this disease show promise in reducing the time to recovery. We present the case of a patient whose infected necrosis extended well into her left paracolic gutter and into her pelvis. We show the advantages of the laparoscopic transgastric technique including ultrasound guidance, mechanical debridement, copious irrigation, advanced hemostasis, and wide internal drainage as well as the dramatic clinical improvement seen in the immediate postoperative period, V398 Single Anastomosis Duodenal-Ileal Bypass with Sleeve (SADI-S) for Treatment of Morbid Obesity Michel Cordies, MD; Alvaro Ducas, MD; Lorna Evans, MD; Rocio Castillo Larios, MD; Fernando Elli, MD, FACS; Mayo Clinic The single anastomosis duodenal-ileal bypass with sleeve (SADI-S) was developed with the intention of simplifying a complex surgical technique. We present a 43-year-old patient, BMI 65, with a medical history of obstructive sleep apnea, GERD, COPD, anxiety disorder and morbid obesity. She declares multiple failure attempts to lose weight with diet and exercise. The patient was a good candidate for a SADI-S. This technique is highly effective as a revision procedure after failed Sleeve Gastrectomy or an option after other failed bariatric procedures. V399 Acute Appendicitis in an Obturator Hernia Nicole A Uzor, MD 1; Loic Tchokouani, MD2; 1Ichan School of Medicine at Mount Sinai; 2New York University School of Medicine The literature is scarce in regard to obturator hernias with incarcerated acute appendicitis. We have a case of a patient who presented right lower quadrant and groin pain. Her workup revealed acute appendicitis herniating into the groin space. What was at first thought to be an Amyand's hernia was, upon operative exploration, found to be an obturator hernia involving an acute appendicitis. This case highlights advantages of the robotic/laparoscopic approach to a groin hernia repair. We performed an appendectomy and explored each potential hernia space. We completed a mesh repair with adequate coverage of each of those spaces. V400 Laparoscopic Revision After SADI (with Intraoperative Endoscopy) for Severe Malnutrition Anne-Sophie Studer, MD; Alexis Deffain, MD; Pierre Y Garneau, MD; Ronald Denis, MD; Radu Pescarus, MD; Hopital du Sacré Coeur de Montréal This video presents a case of severe malabsorption after Single Anastomosis Duodeno-Ileal (SADI) bypass, managed by laparoscopic common channel lengthening with intra-operative endoscopy. The steps of this revisional surgery include: a verification of limb lengths; an endoscopic evaluation of post-pyloric duodenum; confection of Braun entero-enteroanastomosis before transection of the DI anastomosis; creation of a new duodeno-jejunal anastomosis (350 cm proximal to the previous DI); a final endoscopic verification of the newly created anastomosis. An duodeno-jejunal anastomotic fistula with peri-hepatic abcess occurred at POday5, and was managed by laparoscopic drainage, suture and antibiotics. V401 Laparoscopic Morgagni Hernia Repair (Hand-sewn technique) with Mesh Reinforcement Nattida Sapsamarn, MD; Faculty of Medicine Siriraj Hospital, Mahidol University Morgagni hernia is one of a rare congenital diaphragmatic hernia which occasionally presents with an emergency situation as gastrointestinal tract obstruction. The defect closure and mesh reinforcement particularly by laparoscopic approach is challenging. We presented a 78-year-old female who presented with acute obstructed Morgagni hernia. Laparoscopic Morgagni hernia defect closure by hand-sewn technique with mesh reinforcement was successfully performed. She was discharged home uneventfully. Laparoscopic approach is safe and feasible to treat this condition. V402 EUS Guided Drainage of a Postoperative Fluid Collection in the Setting of Roux-en-Y Anatomy Diana Jiang, MD; Rishi Pawa, MD; Wake Forest Baptist Health Pancreatic fistula resulting in postoperative fluid collections remains one of the most severe and common complications following distal pancreatectomy. Failed conservative management of these fluid collections has transitioned from surgical and percutaneous approaches to endoscopic drainage using lumen apposing metal stents (LAMS) as this technique is less invasive and has a lower rate of complications. This case presentation demonstrates feasibility of this technique in a patient with Roux-en-Y anatomy. V403 Robotic-assisted Laparoscopic Ladd's Procedure: A Video Case Report Cullen E Roe, DO; Charles L Cole III, MD; Bogdan Protyniak, MD; Mark E Mahan, DO; Geisinger Intestinal Malrotation is a congenital abnormality that occurs in the 6th–12th weeks of gestation. Patient's typically present with acute symptoms in their first year of life, but a subgroup will present with chronic abdominal pain in their later years. Our case report details a 24-year-old male with history of chronic abdominal pain, who was found to have intestinal malrotation on CT imaging after episode of vomiting. The patient successfully underwent a robotic-assisted Ladd's procedure. V404 Laparoscopic Repair of Concurrent Morgagni and Type III Paraesophageal Diaphragmatic Hernias Lauren Hawley, MD; Karla Bernardi, MD; Kyle A Perry, MD, MBA; The Ohio State University Wexner Medical Center This video demonstrates a laparoscopic repair of concurrent Morgagni and Type III paraesophageal diaphragmatic hernias and Nissen fundoplication. The patient is a 72-year-old female referred for chronic cough and dyspnea by pulmonology. The objective pre-operative workup included endoscopy, manometry, ambulatory pH testing, and CT scan. CT scan demonstrated the concurrent diaphragmatic hernias. Elective repair was performed and the patient recovered uneventfully. Concurrent Morgagni and Type III paraesophageal hernias are a rare entity and have been previously described in case reports. Our objective is to demonstrate that simultaneous repair can be accomplished safely using a minimally invasive, transabdominal approach. V405 Total Thoracoscopic Thymectomy for Thymomatous Myasthenia Gravis: A Video presentation Sumanta Dey, MS, DNB, FNB; Ruby General Hospital & Cancer Center The conventional approach of Thymectomy for Thymomatous Myasthenia Gravis is open thoracotomy. However, its morbidity is very high causing delayed post-operative recovery. The minimally invasive approach, known as Total Thoracoscopic Thymectomy, where only 3–4 keyholes are used to complete the operation. The comparative minimal post-operative pain and fewer pulmonary complication help the patient to go home within 24–48 h. Following is a step-wise video demonstration of Thoracoscopic Thymectomy showing the key steps of performing it safely. Total operating time was 90 min, blood loss was 10 ml. The patient went home after 24 h of Surgery. V406 Robotic Left Adrenalectomy in Patient with Neurofibromatosis Type 1 America S Revere, MD; Andy Nguyen; Aaron Bolduc, MD; Carlos Isales, Dr; Nicki Martinez de Andino, DNP; Medical College of Georgia 27-year-old female with a past medical history of Neurofibromatosis Type 1 was being treated for a thalamic tumor causing obstructive hydrocephalus. After two unsuccessful attempts at operative intervention secondary to unstable supraventricular tachycardia and hypertension upon anesthesia induction, lab and imaging workup demonstrate a left pheochromocytoma. After induction of alpha blockade with an Endocrinology consult and thorough preparation with Anesthesia, the patient underwent robotic left adrenalectomy. Using our 1-min adrenal vein clamp test and on-screen vital signs, the patient underwent successful removal. At her follow-up appointment, the patient had improved vitals and had successfully undergone surgery for her thalamic tumor. V407 Robotic Ladd's Procedure for Intestinal Malrotation Davis Kuruvilla, BS 1; Reagan Sandstrom, BS1; Adham R Saad, MD, FACS2; Joseph Sujka, MD2; 1University of South Florida Morsani College of Medicine, Tampa, Florida; 2Division of General Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida Here we present a 24-year-old female with a past medical history of lifelong nausea and vomiting and a recent laparoscopic cholecystectomy in which intestinal malrotation was discovered. The patient consented to robotic-assisted laparoscopic Ladd's procedure. Ladd's bands were identified and lysed from the duodenum to the splenic flexure, freeing the intestines from malrotation. Appendectomy was also performed. The procedure was successful and relieved the patient's nausea, vomiting, and constipation. V408 Critical Views of Safety in a Laparoscopic Total Mesorectal Excision Deborah S Keller, MS, MD; Taylor P Ikner; John H Marks; Lankenau Medical Center Obtaining the critical view of safety during cholecystectomy is proven to reduce patient complication and increase surgical quality. This concept has not been widely disseminated outside of laparoscopic cholecystectomy to date. Our group standardizes steps of all procedures, and uses this concept to help surgeons ascend the learning curve from competency towards mastery. Here, we demonstrate the steps of a low anterior resection with critical views of safety and patterns a surgeon should recognize during the procedure. Applying this knowledge can help the surgeon safely complete a procedure and know when to use alternative approaches or convert to another platform. V409 Laparoscopic Cholecystectomy with Trans Cystic Common Bile Duct Exploration Following Roux En Y Gastric Bypass Cyril Kamya, MD; Matthew Ballweg, BS; Corrigan L Mcbride, MD; University of Nebraska Medical Centre We present a case of a 68-year-old female with a history of morbid obesity status post Laparoscopic Roux En Y Gastric Bypass who presented with right upper quadrant pain. Work up with ultrasound and MRCP revealed choledocholithiasis with a 7 mm stone in the distal common bile duct and cholelithiasis. Cholangiogram confirmed the obstruction. Direct successful insertion of the choledochoscope into the cystic duct was attained with excellent visualization and retrieval of the choledocholith during the laparoscopic cholecystectomy. This case highlights the efficiency of this one stage laparoscopic procedure for managing choledocholithiasis and avoiding the need for advanced endoscopic procedures. V410 How to Deal with Presacral Bleeding During Laparoscopic Rectal Surgery: Make It Simply Gritcharat Watthanasathitarpha, MD; Prapon Kanjanasilp, MD; Chucheep Sahakitrungruang, MD; Chulalongkorn University This video demonstrates how to deal with presacral bleeding during laparoscopic rectal surgery in a 69-year-old obese male patient who presented with bulky upper rectal cancer and nodal metastasis. When presacral bleeding occurs, The first step is to stay calm and not do blind hemostasis. Direct pressure is adequate for bleeding control and allows time to get better exposure. To achieve fine exposure, removing the tumor should be accomplished. Direct pressure with an absorbable hemostatic agent is recommended. Hemostasis with electrocautery or vessel sealing devices is not recommended and usually leads to further vascular injury. V411 Complications During Bariatric Surgery: Gastric Temperature Probe Gone Awry Sirivan Seng, MD; Joseph Hlopak, DO; Ali Al Tuama, MBBS; Trieu Ton, DO; Aley Tohamy, MD; Crozer Chester Medical Center 53-year-old female with BMI 44.3 presented for robotic Roux-en-Y gastric bypass, however the mesentery of the jejunum was too short to proceed, thus we elected for two-stage procedure. During the stapling of the gastric sleeve, we noted that there was plastic tubing at the staple line. The temperature probe had been incorporated into the gastric sleeve staple line. We converted to laparoscopic procedure and removed both bougie and gastric temperature probe. We stapled off the segment and reinforced with omentum. Post-operatively, gastrointestinal series revealed no evidence of leak. She returned with 80-pound weight loss for conversion to Roux-en-Y gastric bypass. V412 Robotic Transabdominal Preperitoneal (TAPP) Repair of a Spigelian Hernia Yoon Kyung Lee, MD 1; Daniel Tomey, MD1; Roberto Secchi, MD2; Alessandro Martinino, MD3; Rodolfo Oviedo, MD, FACS, FASMBS, FICS1; 1Houston Methodist Hospital; 2Universidad Anahuac Queretaro; 3Sapienza University of Rome Spigelian hernias (SH) represent about 2% of all abdominal wall hernias and 35% occur with a concomitant inguinal hernia. Due to the high risk of bowel incarceration, prompt surgical repair is warranted. This patient presented after recent bowel incarceration and diagnosis of a very low SH at the semilunar line of the right rectus abdominis muscle. The patient underwent an elective robotic TAPP repair with 6 × 4 cm Biosynthetic mesh in the inguinal space. Robotic TAPP repair is a valid repair option for SH including ones occurring very low in the right inguinal space. V413 Anatomic Laparoscopic Partial Hepatectomy of a Segment 4a Beta-catenin Mutated Adenoma Elena Panettieri, MD1; Eduardo A Vega, MD1; Ariana M Chirban, BS2; Oscar Salirrosas, MD 1; Eran Brauner, MD1; Anita Malek, MD3; Richard Freeman, MD1; Claudius Conrad, MD1; 1Department of Surgery, Saint Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA; 2University of California San Diego, School of Medicine, La Jolla, CA, USA; 3Department of Pathology, Saint Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA In this video we present a case in which an Anatomical Laparoscopic Partial Hepatectomy of Segment 4a was performed for a Beta-catenin Mutated Adenoma in a young female patient with a history of hormone replacement therapy. We will cover patient information, surgical port positioning, laparoscopic approach, and important points we gained from this case, highlighting the advantages of preoperative 3D surgical reconstruction and showing that s4 anatomical resection is safe and feasible. V415 Laparoscopic Resection of Enterocutaneous and Colocutaneous Fistula Adrian B Lorenzo, MD; Asian Hospital and Medical Center We present a case of a 58-year-old male who underwent segmental sigmoidectomy with double barrel colostomy for ruptured diverticulitis. The next year his colostomy was taken down but after 2 months a large enterocutaneous fistula formed on his left hemiabdomen. This fistula resolved but recurred to be more active. He underwent colonoscopy which showed strictured anastomotic site. CT scan abdomen showed enterocutaneous fistula formation in left lower abdominal wall probably jejunum and distal descending colon. We successfully performed a laparoscopic wedge resection of the jejunum and segmental left colectomy with primary side-to-side anastomosis. Postoperative course was uneventful. V416 Intraoperative In-Line Holographic Display of Patient-Specific Anatomy During Laparoscopic Right Hemicolectomy for Colon Cancer Alice Moynihan; Faraz Khan; Ronan A Cahill; UCD Centre for Precision Surgery 3d reconstruction of a preoperative mesenteric angiograms allows surgeon visualization of patient-specific anatomy ahead of complete mesocolic excision with central vascular ligation for proximal colon cancer. While this may have additional value for general education, full value requires intraoperative display and ideally projection into the surgical field of view in a way that allows sequential image updating as the operation progresses. Having previously utilized side by side laparoscopic screen-3d recon (VisiblePatient, Strasbourg France) intraop display, here we demonstrate real-time in line projection via mixed reality holographic display (Microsoft Hololens 2, Microsoft). V417 Completion Gastrectomy and Revision of Gastrojejunostomy Anastomosis for Treatment of a Gastrogastric Fistula Fernando Moreno-Garcia, BS; Rachel Tran, BS; Laura E Fischer, MD; Fernando Mier-Giraud, MD; University of Oklahoma Health Sciences Center 57-year-old female with refractory gastroparesis after multiple surgical treatments including botox, pyloroplasty, and RYGB. We are demonstrating minimally invasive surgical management of the complex pathology we believe began with chronic perforation of the gastrojejunostomy. This led to a gastrogastric fistula at the level of the gastrojejunostomy being plastered to the left lower lobe of the liver. The patient was discharged home on postoperative day 7 on a stage 2 bariatric diet with a plan of weaning off TPN as an outpatient. V419 Robotic Rectosigmoidectomy for Endometriosis with Transrectal Piece Extraction D Azambuja1; F Hamaoui1; R Dibi1; LG Romagnolo 2; CR Mendes3; J Iaroseski1; 1UFCSPA; 2Barretos Cancer Hospital / IRCAD Latin America; 3Santa Isabel Hospital Our video reports a robotic rectosigmoidectomy for the treatment of deep endometriosis affecting the sigmoid colon. We highlight the possibility of removing the specimen through a colonoscopic assisted transanal route to spare additional abdominal or vaginal approaches, offering the patient better recovery and aesthetic results. The intraoperative video details the robotic dissection, the use of colonoscopic equipment and the intersection of technological tools to proceed with the piece extraction with less damage as possible. V420 Robotic Abdominal Wall Reconstruction for Recurrent Right Flank and Ventral Incisional Hernia Trieu Do, MD; Corinne E Praska, MD; Kara Vande Walle, MD; Ryan Juza, MD, FACS; UW Madison Wisconsin Hospital and Clinics Herein we present the case of a 67 year old female with recurrent flank hernia. CT demonstrates recurrence of flank incisional hernia with denervation of ipsilateral rectus muscle and retraction of lateral musculature. She was referred to the minimally invasive surgery clinic and offered robotic reconstruction repair with posterior component separation and mesh implantation. Intra-operatively an 8 × 8 cm fascial defect was identified. The previous mesh was removed. Her immediate post-operative course was uneventful, and she was discharged on post-operative day 2. At post-operative follow-up she was recovering well without pain. V421 Laparoscopic Cholecystectomy Based on Laennec Approach via the Cystic Plate with Lymphadenectomy in Calot's Triangle for Gallbladder Neoplasms: initial experience and technical details Decai Yu; Laizhu Zhang; Jin Peng; Nanjing University Aim: It is still challenging to define the exact stage of early gallbladder carcinoma with preoperative imaging. Generally, the subserous gallbladder is dissected for the potential early gallbladder carcinoma, which may cause incomplete tumor resection or tumor spread especially for the patients with T2 stage. Here, we reported our experience and safety of the Laennec approach via the cystic plate to dissect the whole gallbladder with lymphadenectomy in Clot's triangle for accurate diagnosis and staging of gallbladder neoplasms. Methods: The anatomical gap between the Laennec capsule and the cystic plate serves as the landmark to dissect the whole gallbladder through the Laennec approach. Laparoscopic cholecystectomy based on the Laennec approach via the cystic plate, together with lymphadenectomy in Calot's triangular, was performed in 6 patients with gallbladder neoplasms. Results: All patients had less intraoperative bleeding, no gallbladder breakage, no bile leakage, and accurate intraoperative rapid pathological staging under the corresponding strategies. The duration of surgery was comparable to that of traditional laparoscopic cholecystectomy. Conclusion : Laparoscopic cholecystectomy based on Laennec approach via the cystic plate, together with lymphadenectomy in Calot's triangular is safe for gallbladder neoplasms. In the future, a prospective clinical trial is going on to confirm the feasibility and effectiveness in the therapy of early gallbladder. V422 Laparoscopic Ventral Rectopexy with Pelvic Floor Suspension: Left-Sided Approach Tanyawan Heingraj, MD; Chucheep Sahakitrungruang, MD; Chulalongkorn University The standard right-sided approach sometimes encounters poor visualization especially in deep cul-du-sac, redundant sigmoid, and redo-procedure. This novel left-sided approach aims to overcome these technical challenges. Peritoneal dissection on the left side of rectosigmoid colon was started and continued downward to the pelvic floor. The pelvic floor suspension was performed by fixing the mesh to the pelvic floor muscle and S3–S4. The ventral mesh rectopexy was done by fixing anterior rectal wall and posterior vaginal wall to S3. The patient experienced dramatic improvement of defecation symptoms. Postoperative MRI demonstrated reduction of the pelvic floor descent, rectal intussusception, and vaginal prolapsed. V423 Step by Step Instructional Video of Laparoscopic Para-Oesophageal Hernia Repair and Fundoplication for Surgeons-In-Training in a Singapore Institution Aung Myint Oo, MD, FRCSEd, FACS; Charleen Yeo, MD; Tan Tock Seng Hospital, Singapore Tan Tock Seng Hospital is Singapore's second largest acute care general hospital with over 1500 beds. It is a training hospital for both undergraduates and postgraduates. Minimally Invasive surgery becomes more and more popular nowadays. In our department, all the residents and fellows have to view the step by step instructional videos of minimally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant/attending surgeons. The viewing of the instructional videos help them with better understanding of the procedures as well as importance of steps and standardization of steps. V424 A Minimally Invasive Approach to Penetrating Abdominal Trauma in Pediatrics Nathan Foje, MD; Patrick Thomas, MD; Abdalla Zarroug, MD; Angela M Hanna, MD; Children's Hospital & Medical Center, Omaha We present the case of an 18-year-old male who suffered an isolated penetrating abdominal injury with a nail gun resulting in multiple enterotomies and a small mesenteric hematoma. On presentation to our level II pediatric trauma center, he was found to be hemodynamically stable with fascial disruption and concern for intra-abdominal injuries. A laparoscopic approach was used safely to identify multiple intra-abdominal injuries and repair them. Intraoperative video demonstrates the approach used to identify and treat these injuries. The patient recovered expeditiously and was able to be discharged from the hospital on post-operative day one without complication. V425 Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Left Lobectomy and Isthmusectomy Tamanie Yeager; Beselot Birhanu; Gustavo Fernandez-Ranvier; Aida Taye; Mount Sinai Hospital In this video, we describe our experience in transoral thyroidectomy, vestibular approach (TOETVA) on a 44-year-old female with history of hypertrophic scar formation for a 4.5 cm enlarging, symptomatic, benign nodule encompassing the left lobe and isthmus. She underwent a left lobectomy and isthmusectomy utilizing the transoral approach. Unique in this case: due to the specimen size, transcutaneous aspiration was performed under direct endoscopic visualization to reduce the specimen volume, and a small cervicotomy was also required for extraction. Critical structures including the left recurrent laryngeal nerve, the left superior and inferior parathyroids have excellent visualization during the case. V426 Robotic assisted Ile-Colonic Fistula Takedown via Suprapubic Approach and Two Intra-Corporeal Anastomoses Matthew Wynn, MD; Rahila Essani; Baylor Scott and White Health This video shows the operative approach of a robotic-assisted laparoscopic ileocecectomy and segmental colectomy for an ileocolonic fistula in a 78-year-old female with a new diagnosis of Crohn's disease. She had a CT enterography and a colonoscopy preoperatively, which both showed the presence of this ileocolonic fistula. Lysis of adhesions was first performed, after which the fistula was interrogated. Due to the disease on the ileum, an ileocecectomy was performed with a side-to-side ileocolonic anastomosis. The colonic side of the fistula was also resected, with a hand-sewn end-to-end anastomosis. These were both performed via a suprapubic approach robotically. V427 Early, Acute Roux Limb Obstruction Status Post Conversion of Sleeve to Laparoscopic Roux-en-Y Gastric Bypass Berna F Buyukozturk, MD; Susan K Campbell, MD; Wasef Abu-Jaish, MD; University of Vermont Medical Center A 43-year-old female underwent laparoscopic conversion from sleeve gastrectomy to Roux-en-Y gastric bypass, complicated by obstruction at the jejuno-jejunostomy (JJ) in the immediate postoperative period. Our video shows the anastomosis folded on itself due to orientation and weight of the small bowel. The Roux limb was divided at the JJ, and was re-anastomosed, hand-sewn, distally. An anti-obstruction stitch was described by Dr. Brolin in 1994 to prevent kinking at the JJ in a gastric bypass. The "Brolin" stitch has been used in revisional surgery to relieve obstruction. Our case illustrates the potential of an anti-obstruction stitch to prevent kinking. V428 Roux-en-Y Gastric Bypass Reversal for Recurring Calcium Oxalate Stone Formation Jason M Samuels, MD; Matthew Spann, MD, MMHC; Brandon Williams, MD; Wayne English, MD; Vanderbilt University Medical Center This video details a gastric bypass reversal. The case is a 69-year-old man with history of recurrent infected calcium oxalate stones necessitating bilateral nephrectomies. The renal transplant team attributed his recurrent stones to his gastric bypass and recommended that he undergo reversal prior to being listed for kidney transplant. The patient was found to have a retrocolic roux limb that was relatively short in length. He was thus managed with resection of his roux limb with a gastrogastrostomy using a 25 mm circular stapler. The patient also required a concurrent hiatal hernia repair. V429 Robotic Bilateral Transversus Abdominis Component Separation and Diaphragmatic Hernia Repair in an Immunosuppressed Heart Transplant Patient Steven M Elzein, MD; Mu'ath Adlouni, BS; Ahad Azzimuddin, BS, MBA; Rodolfo J Oviedo, MD, FACS, FSMBS; Houston Methodist Hospital Over 400,000 ventral hernia repairs are performed annually in the U.S. Nearly 10% of patients presenting for elective ventral hernia repair are on immunosuppression, most commonly due to prior organ transplantation. Recent studies have demonstrated mixed results regarding the success and feasibility of transversus abdominis muscle release (TAR) in immunosuppressed patients. We present the case of a 59-year old chronically immunosuppressed patient who underwent robotic bilateral transversus abdominis component separation and diaphragmatic hernia repair following heart transplantation. While TAR remains a possible therapeutic technique for immunosuppressed patients, careful surveillance is key as they may exhibit higher risk for post-operative complications. V430 Robotic-Assisted Heller Myotomy and Toupet Fundoplication Re-do Lorna A Evans, MD; Alvaro Ducas, MD; Rocio Castillo-Larios; Michel Cordies; Enrique F Elli, MD, FACS; Mayo Clinic We present a 26-year-old patient with a Medical History achalasia s/p Heller myotomy with partial fundoplication in August of 2015 performed at another Institution. The patient intercurred in 2022 with symptoms of Gastroesophageal Reflux disease, heartburn with little relief of her daily PPI, dysphagia to solid foods and regurgitation. V431 A Minimally Invasive Approach to Suspected Ischemic Bowel, A Case Report: Diagnostic Laparoscopy for SBO s/p RYGB Lena A Shally, BA 1; Michael A Blazaskie, MS, BS1; Daman R Bowman, DO2; Ryan D Horsley, DO2; 1Geisinger Commonwealth School of Medicine; 2Geisinger Health System A 55 year-old female presented with severe, persistent abdominal pain s/p Roux-en-y gastric bypass surgery. Physical exam was significant for fever and diffusely tender abdomen with involuntary guarding. Severe wall thickening in the mid-abdominal small bowel with moderate mesenteric and peritoneal edema was noted on CT, concerning for ischemic bowel. The decision was made to perform diagnostic laparoscopy, disclosing a postoperative diagnosis of adhesive SBO without perforation or necrosis. This case and supportive findings highlight the use of diagnostic laparoscopy in investigating the extent of disease prior to laparotomy when there is high suspicion of bowel necrosis on imaging. V433 Laparoscopic Management of Post-cholecystectomy Bleeding Leslie M Okorji, MD; Caroline E Reinke, MD; Carolinas Medical Center We are presenting a case of laparoscopic management of post-cholecystectomy bleeding. Our patient is a 49 year old female who presented to our hospital on POD1 following laparoscopic cholecystectomy at outside hospital with progressive abdominal pain, tachycardia, peritonitis and lactic acidosis. CT scan demonstrated abdominal free fluid of unclear etiology. The patient underwent diagnostic laparoscopy and was found to have hemoperitoneum with venous oozing from the gallbladder fossa. This was successfully managed laparoscopically using combination of hook cautery, hemostatic agents and direct pressure, and she did well postoperatively. There are multiple etiologies of post-cholecystectomy bleeding, and early recognition is paramount. V434 Infected Urachal Sinus Presenting as Abdominal Wall Abscess: A Case Series Khuram Khan, MD; Selim Gebran, MD; Mohammad Gilani, MD; Wyckoff Heights Medical Center Urachal remnants are rare anatomical defects and can easily be missed by clinicians. We report three cases of urachal sinus with their management. The ages of the patients were 12, 26, and 38 respectively, and all were males. All patients presented with umbilical abscess with leukocytosis and imaging showing abdominal fluid collection. Pathology showed fibromuscular soft tissue with benign urothelial epithelium. The post-operative recovery of all the patients was uneventful. Early diagnosis and proper management of urachal remnant abnormalities is crucial in preventing recurrent infections and long-term complications associated with them. The rarity of the disorder prevents universal screening guidelines. V435 Robotic-assisted Nissen Takedown and Conversion to Toupet Rocio Castillo Larios, MD; Michel Cordies Perez, MD; Lorna Evans, MD; Alvaro Ducas, MD; Enrique F Elli, MD, FACS; Mayo Clinic Florida Nissen fundoplication is the most commonly performed anti-reflux surgery. Laparoscopic Nissen fundoplication fails in approximately 2–17% of the patients, with reflux recurrence and dysphagia being the most common reasons for re-operation. Although the re-operation success rate goes between 78–81%, the morbidity and mortality associated with the re-intervention are also high. Due to the presence of adhesions, the surgical field becomes more complex. We present the case of a 67-year-old female with history of severe daily reflux and heartburn status post Nissen fundoplication. V436 Transgastric GIST Resection Jack R Thorburn, MSc, MSc, PT 1; Bradley Evans, MD1; James Ellsmere, MD2; 1Memorial University of Newfoundland; 2Dalhousie University This video demonstrates a laparoscopic transgastric resection of a bleeding gastrointestinal stromal tumor in an 83-year-old male. This mildly demented patient presented with anemia from an ulcerated lesion in the stomach. The patient underwent endoscopy for consideration of resection which revealed a 6 cm endophytic lesion that was not considered to be endoscopically resectable. The patient was brought to the OR and underwent a successful lesion removal. Our video demonstrates a low morbidity alternative to endoscopic resection for large lesions in the stomach. V437 Robotic Assisted Reduction of Small Bowel Internal Hernia around a Fallopian Tube Joseph A Sciacca, DO; Anthony Tascone, MD; Caitlin Halbert, DO; ChristianaCare 41-year-old female with two cesarean sections and a 5-year history of abdominal pain requiring hospitalization, presented with 36 h of abdominal pain. CT imaging demonstrated small bowel obstruction. She underwent robotic adhesiolysis following a diagnostic laparoscopy. Two loops of densely adhered small bowel were encountered; the first to the anterior abdominal wall, and the other, to the uterus. A loop of small intestine wrapped under the left fallopian tube was discovered, creating an internal hernia, which was carefully relieved. The adhesiolysis of the small bowel created serosal injuries, which were repaired with PDS Stratafix suture, without the need for enterectomy. V438 En Bloc Resection of PEG Site Oropharyngeal SCC Recurrence with Complex Abdominal Wall Closure AJ Haas, MD; Clara Kit Nam Lai, MBBS; Hemasat Alkhatib, MD; Angela Thelen, MD, MHPE; Y. Kelly Zhang; Alejandro Feria, MD; Sergio Bardaro, MD, FACS, FASMBS; Amelia Dorsey, MD; Kevin El-Hayek, MD, FACS; MetroHealth Medical Center PEG site metastases from head and neck cancers are rare. However, these recurrences are particularly devastating in patients who remain unable to swallow following initial resection. Alternatives exists, yet a vast majority of PEG tube procedures utilize a 'pull' method. For patients who experience this complication, the detriment is two-fold. In addition to recurrence, resection of the abdominal wall necessitates thoughtful methods of closure. The case shown in this video demonstrates en bloc resection of a PEG site metastases of head and neck origin with subsequent complex abdominal wall closure. V440 Colonic Stenting as a Bridge to Surgery for obstructing Rectosigmoid Tumor Sonal Kaushik, DO; Abubaker Ali, MD, FACS; Sinai Grace Hospital—Detroit Medical Center Recent literature has shown the use of colonic stenting for bridge to definitive surgery as a safe option for patients presenting with malignant bowel obstruction. Here we present a case of colonic stenting for an obstructing colon lesion and subsequent colectomy. The patient is a 56-year-old male presenting with rectosigmoid tumor who underwent placement of colonic stent over a biliary catheter, followed by robotic assisted low anterior resection. This case demonstrates a minimally invasive approach to large bowel obstruction secondary to malignancy and showcases the use of a biliary balloon catheter to assist in tumor localization and stent deployment. V441 Robotic Median Arcuate Ligament Syndrome Release Nicole Hadjiloucas, MD; Zoe Guzman-Rivera, MD; Jessica Treto, MD; Stephen Pereira, MD; George Mazpule, MD; Adam Rosenstock, MD; Hackensack University Medical Center This video depicts a robot assisted median arcuate ligament release for a 39 year old female with chronic abdominal pain and food intolerance. Patient presented to the emergency department and was found to have celiac artery stenosis at origin. Full workup was performed including abdominal ultrasound and mesenteric angiogram. Decision was made to perform a robotic release of the median arcuate ligament. Patient tolerated the procedure well and was discharged home with a drain tolerating diet without difficulty, her symptoms resolved. V443 Robot-Assisted Enucleation of an Esophageal Leiomyoma Daniel W Kim, MD; Ammar Humayun, MBBS; Praveen Satarasinghe, MD, MBA; Niteesh Sundaram, MD, MS; Elisa Kershaw, PA; Joseph D Whitlark, MD; Crozer Chester Medical Center We present a case of an esophageal leiomyoma that was resected by a robot-assisted transthoracic approach in an otherwise healthy 50-year-old woman. Her presenting complaint was dysphagia. Computed tomography of the chest without contrast demonstrated a 4-cm mediastinal mass involving the mid-esophagus. Upper endoscopy and an endoscopic ultrasound with fine needle aspiration revealed that this was a mid-esophageal leiomyoma with its inferior border at the level of the azygous vein. The procedure was successful without complications. A post-operative contrast esophagram showed no evidence of leak or stricture, and the patient was discharged after she tolerated a clear liquid diet. V444 Laparoscopic Conversion of a Loop Jejunostomy Feeding Tube to a Roux-en-Y Kristen Wong, MD 1; Amber Shada, MD, FACS2; 1University of Alabama at Birmingham; 2University of Wisconsin at Madison The traditional loop jejunostomy tube is known to be fraught with complications, especially for those patients that require long term or permanent post pyloric feeding access. These complications include leakage of enteric contents from around the tube and difficult re-insertion into the correct, efferent limb at the bedside. For those who require permanent enteral feeding access or those who have experienced these complications, a Roux-en-Y jejunostomy tube is a good alternative. Here, we describe the steps and helpful tips in a conversion from a loop jejunostomy to a Roux-en-Y jejunostomy. V445 Laparoscopic Assisted Whipple's Procedure—Our Technique of Resection Krishna Asuri; Virinder Bansal; AIIMS, New Delhi Whipple's pancreaticoduodonectomy is the standard procedure for resectable periampullary carcinoma. In this video we would like to demonstrate our technique of laparoscopic resection using ligasure. The entire resective phase took 90 min. V446 Robotic Gastrojejunostomy in a Patient with Duodenal and Proximal Jejunal Crohn's Disease Salvatore Parascandola, MD; Paula Marincola Smith, MD, PhD; Aimal Khan, MD; Vanderbilt University Medical Center Surgery for proximal small bowel Crohn's comprises < 1% of surgical procedures for Crohn's. Procedures include strictureplasty and bypass. We present a case of a 53-year-old male with stricturing Crohn's disease involving the duodenum and jejunum. Despite maximal medical therapy, he was unable to tolerate food and required total parenteral nutrition. He underwent a robotic gastrojejunostomy, bypassing his active disease with a gastrojejunal anastomosis created 60 cm distal to the Ligament of Treitz. He was discharged on postoperative day 5 tolerating food by mouth, and no longer requiring Total Parenteral Nutrition. V447 Laparoscopic Reduction and Pexy of Anastomotic Intussusception Following Gastric Bypass Daiji Kano, MD; Kathryn Schlosser, MD; John Scott, MD, FACS, FASMBS; Prisma Health The incidence of intussusception following laparoscopic gastric bypass is 0.1–1.2%. Most are retrograde—from the common channel into the Roux limb. Proposed risk factors include significant weight loss resulting in the thinning of the mesentery and disruption of the pacemaker activity in the myenteric plexus resulting in dysmotility. Anastomotic size and technique may be additional risk factors. We present a case of intussusception associated with significant weight loss following laparoscopic gastric bypass that was treated successfully with laparoscopic reduction and suture pexy. We also describe the three distinct types of anastomotic techniques used in our practice. V448 All You Can (Endo)suture! Different Application of the Apollo OverStitchTM Endoscopic suturing System in Both Elective and Emergency Setting Alfonso Lapergola, MD 1; Antonio D'Urso, MD, PhD1; Didier Mutter, MD, PhD, FACS, FRSM2; Jacques Marescaux, MD, FACS, HonFRCS, HonFJSES, HonAPSA3; Silvana Perretta, MD, PhD3; 1Visceral and Digestive Surgery Department, Nouvel Hôpital Civil (NHC), 1, place de l'Hôpital, 67091 Strasbourg, France; 2Institute of Image-Guided Surgery (IHU), 1 place de l'Hôpital, 67091 Strasbourg, France; 3IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France Here we show the use of Apollo OverStitchTM in addressing different procedures from primary and revisional endoluminal bariatric procedures to rescuing gastrointestinal surgery complications. The first case is an endoscopic sleeve gastroplasty. The second case illustrates its use with Argon plasma application for Transoral outlet reduction procedure for weight regain post-RYGB. The third case shows the endoscopic treatment of a "candy cane" syndrome in an 83 years-old patient with complex surgical history. The last case concerns the successful treatment of an acute oesogastric anastomotic dehiscence after recent gastroepiploic embolization in a 74 years-old man with history of left hemicompartmentectomy. V449 Intraoperative Video Consultation Facilitates Same Day Repair of Bile Duct Injury During the Covid Pandemic Britney Niemann, MD; Michael Sestito, MD; Carl Schmidt, MD, FACS; James W Marsh, MD, FACS; Brian Boone, MD, FACS; West Virginia University During an elective laparoscopic cholecystectomy, a rural surgeon at an outside facility identified a common bile duct transection. Our institution was at maximum capacity secondary to COVID with transfer times of several days. An intraoperative video consultation with our surgeon was obtained, enabling a real-time explanation of the dissection and visualization of the cholangiogram. The patient was accepted directly to the operating room for robotic roux-en-y hepaticojejunostomy and recovered well. The accepting surgeon’s ability to visualize the injury during the index operation facilitated early biliary reconstruction. Intraoperative video consultation can be informative and expedite reconstruction after bile duct injuries. V450 Laparoscopic Resection of a Recurrent GIST after Pancreaticoduodenectomy Varun V Bansal, MBBS 1; Hunter Witmer, MD, MBA1; Divya Sood, MD2; Cecilia Ong, MD1; Ankit Dhiman3; Mitchell Posner, MD1; Kiran Turaga, MD, MPH1; 1University of Chicago; 2Oregon Health & Science University; 3Medical College of Georgia, Augusta University This video describes the laparoscopic resection of a recurrent gastrointestinal stromal tumor (GIST). The patient is a 61-year-old female who originally underwent a pylorus-preserving pancreaticoduodenectomy for an incidentally detected pancreatic GIST in 2010. In 2021, she was found to have recurrent disease in the right upper quadrant with tumor abutting the liver, right kidney, small bowel and her pancreaticobiliary limb. She received neoadjuvant imatinib followed by laparoscopic resection in July 2022. This video highlights a challenging case due to adhesions and her post-Whipple anatomy while adhering to the operative principles for GIST resection. V451 Robotic Resection of a Type I Choledochal Cyst with Hepaticoduodenostomy Reconstruction Lauren E Edgar, MD 1; Hamza Chaudhary, MD1; Carisa R Champion, DO1; Gregory W Kunis2; Ziad T Awad, MD1; 1University of Florida Jacksonville; 2Nova Southeastern University College Of Osteopathic Medicine Presented is the robotic resection of a Type I choledochal cyst with hepaticoduodenostomy reconstruction. First, the common bile duct is skeletonized from the intrapancreatic portion to its bifurcation. Adhesions of remnant cystic artery and duct from a prior cholecystectomy are detached from the liver with electrocautery and a clip. The cyst is transected proximally with cautery at the duct bifurcation and then transected distally with a 45 mm endoscopic stapler. A Kocher maneuver is performed, mobilizing the duodenum, and hepaticoduodenostomy reconstruction is performed using 3–0 self-locking absorbable suture. Indocyanine-green fluorescent cholangiography is used during the procedure to better demonstrate biliary anatomy. V452 Chyloperitoneum Associated with Petersen’s Hernia John W Keyloun, MD; Whitney P Sutton, MD; J R Salameh, MD, FACS; Medstar Georgetown University Hospital In this video, we describe a patient with a history of Roux-en-Y gastric bypass who presents with an internal hernia. On diagnostic laparoscopy chyloperitoneum and a considerable herniation of small bowel through a mesenteric defect between the Roux limb and transverse mesocolon is discovered. Recent research has explored the phenomenon of chyloperitoneum in gastric bypass patients and has found that this finding is relatively common in the setting of Petersen's defect hernias in patients with considerable weight loss following bariatric surgery, while the etiology of this phenomenon is unknown, the finding is illustrated by this case presentation. V453 A Case Presentation: Endoscopic Sleeve Gastroplasty Stephanie Joseph, MD, MPH 1; Vanessa N Vandruff, MD2; Julia R Amundson, MD, MPH2; Simon Che, MD3; Shun Ishii, MD3; Chris Zimmermann, MD3; Mason Hedberg, MD3; Michael B Ujiki3; 1Wayne State University; 2The University of Chicago; 3The NorthShore University HealthSystem Endoscopic Sleeve Gastroplasty (ESG) is an endoscopic technique that uses a suture apparatus over an endoscope to narrow the lumen of the stomach with a series of U-Stitch patterned bites. Satisfactory weight loss is achieved through an incisionless method and patients are routinely discharged the same day. ESG is reversible and can be converted to other bariatric procedures if ever required. This video will walk through ESG as it is approached at NorthShore University Hospital HealthSystem. V454 Intra-Thoracic Abdomen: A Case of Massive Para-Esophageal hernia Repair Heba Alfaris, MD 1; Chao Li, MD, MSc, FRCSC2; Namdar Manouchehri, MD, MSc, FRCSC, CIP2; 1University of Montreal; 2CIUSSS de l'Est de l'Ile de Montreal Type IV para-esophageal hernia (PEH) contains the stomach and other abdominal organs. This 74-year-old lady presented to the emergency room for a hip fracture and an abnormal chest radiograph during her admission prompted investigations. She reported epigastric & retrosternal pain and early satiety at follow up yet no significant dysphagia. Her PEH contained nearly all the hollow organs of the abdomen. Ultimately, surgical repair was performed and the video presents the operative approach to such a massive PEH. V456 Novel Use of Laparoscopic Totally Extraperitoneal (TEP) Approach for Removal of an Abdominal Wall Foreign Body Min Yun Ho, MRCS, MBBCHBAO; Jeremy Tan; Benjamin Poh; Eugene Lim; Tiffany Lye; Zhen Jin Lee; Gautham Palaniappan; Ryan Sam; Ain Nurul; Sachin Mathur; Singapore General Hospital A 39 year-old lady with Down's syndrome presented with right iliac fossa pain to the emergency department. Computed tomography abdomen pelvis revealed a foreign body in the right lower anterior abdominal wall. We report the first case of using laparoscopic totally extraperitoneal (TEP) approach to remove an ingested foreign body that likely perforated through the gastrointestinal tract and subsequently migrated to the anterior abdominal wall. Granted, the laparoscopic TEP approach is more widely used in inguinal hernia mesh repairs and increasingly prostatectomies, we believe that the TEP approach could also be used in a novel fashion as in this case. V457 Laparoscopic Resection of Duodenal Neuroendocrine Tumor Omar AlQabandi, MD 1; Dalia Albloushi, MD2; Danah Quttaineh, MD1; Muneerah AlMuhaini, MD1; Abdullah Alfawaz, MD3; Abdulrahman M Husain, MD4; Ahmed Sayed Hashim, MD2; Salman Alsafran, MD3; 1Jaber Alahmed Hospital; 2Mubarak Alkabeer hospital; 3Kuwait University Faculty of Medicine; 4Military Hospital Neuroendocrine tumors (NETs) are neoplasms arising from the peripheral neuroendocrine system, affecting different organs. The most common types of upper gastrointestinal tract neuroendocrine tumors are the gastric and duodenum NET. Twenty percent of duodenal NET occur in the periampullary region. Management of such tumors include endoscopic or surgical resection. Surgical resection is typically warranted in most duodenal NETs. We present a laparoscopic wedge resection of a duodenal neuroendocrine tumor. V458 Robotic Pancreaticoduodenectomy with Cholecystectomy for Pancreatoblastoma Sharona Ross; Rishi Ashwath; Iswanto Sucandy; Alexander Rosemurgy; Digestive Health Institute Tampa This video demonstrates a robotic pancreaticoduodenectomy for a pancreatoblastoma with a concomitant cholecystectomy. A 42-year-old man presents to clinic for evaluation of a pancreatic an enlarging neuroendocrine in the head of the pancreas. Preoperative workup included CT scan and EUS/FNA which were all consistent with neuroendocrine tumor. Dissection, resection, and reconstruction were undertaken without any complications. 10-French flat JP along the hepaticojejunostomy and pancreaticojejunostomy anastomosis. Pathology showed not neuroendocrine tumor but instead pancreatoblastoma with no evidence of invasive carcinoma. This video shows how a pancreaticoduodenectomy with cholecystectomy, a complex HPB operation, can be safely undertaken with the robotic platform. V459 Laparoscopic Left Adrenalectomy for Conn's Syndrome due to Adrenal Adenoma Sumanta Dey, MS, DNB, FNB; Ruby General Hospital & Cancer Center Conn's syndrome is also known as primary hyperaldosteronism. Adrenal adenomas are one of the important causes of Conn’s syndrome. Adrenalectomy is the definitive treatment for these patients. Laparoscopic adrenalectomy, although technically challenging, gives patients a pain-free rapid recovery. Proper pre-operative optimization is the key to achieving a successful outcome. Here, I am sharing a video showing the state-of-the-art techniques for performing Laparoscopic Adrenalectomy. Total operative time was 90 min and approximate blood loss was 10 ml. V460 Cosmetic Cholecystectomy: Utilizing Robotics to Achieve an Aesthetic Outcome Joseph Greene, MD, MBA, FACS, FASMBS; Holy Cross Germantown Hospital Cholecystectomy is of the most common general surgical procedures performed. When performed laparoscopically, multiple incisions and their resultant scars are left in the epigastrium and right upper quadrant. In appropriately selected patients, the use of robotics allows for placement of incisions in cosmetically appealing locations—particularly along the bikini line in the lower abdomen and the cephalad aspect of the umbilicus, where the scars will be less visible. This video demonstrates preoperative planning, incision placement, positioning, as well as the technical execution of robotic cholecystectomy in this manner while adhering to the principles of the Critical View of Safety method. V461 Laparoscopic and Endoscopic Cooperative Surgery (LECS) for Gastrointestinal Stromal Tumor Involving the Second Portion of the Duodenum Hariruk Yodying, MD; HRH Princess MahaChakri Sirindhorn Medical Center, Srinakharinwirot University A gastrointestinal stromal tumor (GIST) at the 2nd duodenum is surgical challenging because of its anatomical location and proximity to the pancreas. However, Laparoscopic endoscopic cooperative surgery (LECS) for selected duodenal GIST is feasible and associated with acceptable operative outcomes. Therefore, we presented the patient with duodenal GIST located on the antimesenteric border of the second part of the duodenum underwent full-thickness excision using the LECS method. As a significant defect of the duodenum,The reconstruction was Roux-en-Y duodenojejunostomy. Recovery was uneventful. V462 Single Port Cholecystectomy Ahmed Abdelhady; Mohamed Alqaydi, MD; Zayed Military Hospital UAE Single-port laparoscopic (SPL) cholecystectomy is performed under GA in supine position. Through an umbilical incision a 3- trocars are introduced throught the gelport cap. The gallbladder is lifted cranially to the liver using a straight laparoscopic clamp. The procedure is the same as the multiport procedure. Before ligation of the cystic duct and artery a critical view of safety is achieved. If no critical view of safety can be achieved an extra trocar will be placed or the procedure is converted to an conventional procedure. V463 Robotic Assisted Laparoscopic Identification and Bypass of Lymphoma Stricture at Ligament of Treitz Miles Dale; Rishi Sharma; Seth Peterson; George Mazpule; Adam Rosenstock; Stephen Pereira; Hackensack University Medical Center We present a robotic assisted laparoscopic identification and bypass of lymphoma stricture at ligament of treitz at Hackensack University Medical Center. This is a 60 year old male with past medical history of diffuse large B cell lymphoma of the jejunum at ligament of treitz presented post chemotherapy with four days of worsening abdominal cramping pain and an episode of vomiting consistent with small bowel obstruction at ligament of treitz on CT scan. We elected for a minimally invasive approach for identification as we were uncertain how resectable the area of stricture would be. V464 Laparoscopic Dor Fundoplication Takedown with Repair of Incidental Esophagotomies Kara Vande Walle, MD; Luis Felipe Okida, MD; Raul Rosenthal, MD; Cleveland Clinic Florida This is a 54 year-old woman with Type II Achalasia who underwent prior dilation and laparoscopic Heller with Dor fundoplication two years prior. She initally improved after her operation but developed recurrent dysphagia and emesis. A laparoscopic takedown of the Dor fundoplication and lengthening of the myotomy was performed. During the operation, several incidental esophagotomies were made and repaired. Postoperatively, the patient had no leak on upper GI and improvement in her symptoms. V465 Injury of the Posterior Wall During the Ileo Colic Anastomose Luis Romagnolo, MD 1; Armando Melani, MD, MsC2; Paulo Bertulucci2; Carlos Veo, MD, MsC, PhD3; Felipe Diniz, MD3; Marcos Denadai, MD, MsC, PhD3; 1Ircad América Latina/ Barretos Cancer Hospital; 2Ircad América Latina/ Americas Medical Center; 3Barretos Cancer Hospital Here, we present 1 video about a complication during a right colectomy. During the anastomoses side by side when you have to open the colon we open the anterior and we saw that we opened the posterior wall also. The aim of this video is to show how to treat this complication. We performed a simple and single suture using a prolene 3–0 and finished the intracorporeal anastomoses with no complications and the patient. V466 Laparoscopic Feeding Jejunostomy Tube Insertion Eric Hempel, MD; Daniel French, MD; Dalhousie University This is a demonstration of a laparoscopic J tube placement. It incorporates the creation of a Witzel tunnel to decrease feed reflux and local site complications. We utilize a combination of the Endo Stitch device and traditional laparoscopic suturing for the procedure. Port placement maximizes operative space and optimizes the working angles for suture placement. It also allows for placement of the tube through the rectus sheath. This procedure was combined with a laparoscopic assisted PEG tube placement, that portion of the procedure has been omitted. Thank you for your consideration. V468 Robot Assisted Laparoscopic Excision of a Retroperitoneal Mass with en bloc Partial Splenectomy Jessica Treto, MD; Sarah Bryczkowski, MD; Alexander Bonte, MD; George Mazpule, MD; Adam Rosenstock, MD; Stephen Pereira, MD; Hackensack University Medical Center This video describes a robot assisted laparoscopic excision of a retroperitoneal mass with en bloc partial splenectomy. This was performed on a patient who had a progressively enlarging mass that was intimately adhered with the lower pole of the spleen. Indocyanine green fluorescence was used to demarcate the transition between ischemic spleen and perfused spleen prior to transection. V469 Laparoscopic Management of Appendiceal Mucocele: Is it Safe? Can It Be Done? Susan K Campbell, MD; Berna F Buyukozturk, MD; Wasef Abu-Jaish, MD; University of Vermont Medical Center A 46-year-old female with no significant past medical history presented with pelvic pain. A transvaginal ultrasound was concerning for a dilated appendix consistent with a mucocele which was also visualized with CT scan. Our video demonstrates safe laparoscopic technique for handling of an appendiceal mucocele, imbrication of the staple line to avoid spillage of mucin, and appropriate retrieval of the specimen with care taken to avoid rupture of the endoscopic retrieval bag. Her post operative course was uneventful, and she was followed with serial tumor markers and CT scans to monitor for recurrence or progression to pseudomyxoma peritonei. V470 Robotic Standardized Dor Fundoplication Andres Latorre- Rodriguez, MD; Sumeet K Mittal, MD; Norton Thoracic Institute, St Joseph's Hospital and Medical Center This video presents a standardized technique for performing robotic partial anterior fundoplications, highlighting the meticulous division of the gastrohepatic ligament, dissection and mobilization of the hernial sac, complete exposure of the right and left crus, correction of hiatal defect, and division of short gastric vessels. Fundoplication is created in a standard fashion, starting with an Angle of His accentuation (A.O.H fundoplasty) and an anterior fundoplication. A standard technique represents a sequential, logical, and organized surgical approach to a reproducible surgical fundoplication. V471 Laparoscopic Splenectomy for Splenic Artery Aneurysm Karl Hage 1; Ishna Sharma1; Marita Salame1; Avantika Narasimhan1; Travis McKenzie1; Benjamin Clapp2; Omar M Ghanem1; 1Department of Surgery, Mayo Clinic Rochester, MN.; 2Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX We describe the case of a 36-year-old female who presented with a 2.1 cm pre-operative splenic artery aneurysm on imaging. She also had an accessory spleen at medial aspect that we aimed to preserve in order to potentially maintain splenic function. She was treated with laparoscopic splenectomy. A 3.1 cm aneurysm was removed, and the accessory spleen had preserved vascular supply. Patient had no post-operative complications and 3-week follow-up showed favorable results. In conclusion, laparoscopic splenectomy remains the mainstay and definitive treatment for splenic artery aneurysm. V472 Robotic-assisted Nissen Fundoplication Takedown and Conversion to Gastrojejunostomy with Roux-en-Y Reconstruction Naga Swati Gunturu, MD; Rocio Castillo Larios, MD; N. Busra Celik, MD; Enrique F Elli, MD, FACS; Mayo Clinic Florida Nissen fundoplication is a standard anti-reflux surgery. However, some patients can present with recurrence of reflux symptoms, herniation of wrap, or severe gastroparesis following a Nissen procedure. Some patients may also have obesity (BMI > 30) or associated comorbidities. In such patients, a revisional surgery with Roux-en-Y is preferred. This not only helps with the symptoms of reflux and gastroparesis, but also in weight loss and associated comorbidities. We present the case of a 54-year-old female status post-Nissen fundoplication with reflux recurrence, gastroparesis, herniation of the wrap, and failure to lose weight. V473 Chronic Groin Mesh Infection with Femoral Vessel Involvement Cameron Casson, MD; Jeffrey Blatnik, MD; Washington University in St. Louis Case is of a 65-year-old female with two previous left inguinal hernia repairs who presented with a chronic mesh infection. She was taken to the operating room for removal of multiple pieces of mesh in a combined robotic and open approach. Mesh was found to be adherent to the femoral vein and artery. A common femoral vein injury occurred, which required Vascular Surgery assistance for repair. Subsequently, Plastic Surgery was involved for flap coverage of the exposed femoral vessels. V475 Laparoscopic Completion Pancreatectomy for PDAC Recurrence Post Open Pancreatoduodenectomy Sara A Alkhaja, MD 1; Noaman Ali, MD2; Juan S Barajas-Gamboa, MD1; Essa M Aleassa, MD1; 1Cleveland Clinic Abu Dhabi; 2Cleveland Clinic Ohio Laparoscopic approach following open pancreatoduodenectomy has received considerable attention and remains controversial. A 55-year-old male post open-pancreatoduodenectomy for pancreatic head adenocarcinoma, developed a recurrence in the remnant pancreas two-years later. Multidisciplinary consensus was to proceed with laparoscopic completion pancreatectomy. Diagnostic laparoscopy with adhesiolysis was performed to identify the pancreaticojejunostomy, then divided. The pancreatic remnant was then dissected off the retroperitoneum. Different methods to hemostasis were utilized. Operative-time was 420 min with no complications. The five-days postoperative course was uneventful. The final pathology reported an Invasive well-to-moderately differentiated adenocarcinoma. Laparoscopic approach to complex abdominal surgery post open-procedures is feasible. V476 Novel Robotic-Assisted Laparoscopic Liver Resection Technique Using The Ultrasonic Scalpel Device Michelle H Kim, MD; Jonathan Delong, MD; Brendan Visser, MD; Kazunari Sasaki, MD; Stanford University Parenchymal transection in robotic-assisted laparoscopic liver resection (RLLR) relies on techniques such as using a laparoscopic CUSA device employed by a bedside assistant or crush clamping tissue with robotic vessel sealers to combine hemostasis with imprecise parenchymal dissection. Here we introduce a novel liver parenchymal transection technique utilizing a robotic Harmonic scalpel as a substitute for the CUSA for parenchymal transection in RLLR. This technique allows for liver tissue to be precisely dissected by the active blade without injuring large vessels. With this technique, the surgeon can perform RLLR autonomously without frequent instrument exchanges or support from the bedside surgeon. V477 Robotic-assisted Laparoscopic Ladd’s Procedure in the Adult Patient Simon N Chu, MD, MS; Fernanda Romero-Hernandez, MD; Amar Nijagal, MD; Ankit Sarin, MD; Kimberly S Kirkwood, MD; University of California, San Francisco We present a case of an adult patient with abdominal pain, nausea, and fatigue, who was diagnosed with congenital intestinal malrotation. We performed a robotic-assisted laparoscopic Ladd's procedure and found dilation of the 1st and 2nd portions of the duodenum proximal to adhesions to the retroperitoneum with twisting of D3 and D4. We also found a second area of adhesions causing an adhesive twisting of a portion of the ileum. The robotic approach may be superior in the adult patient due to improved ergonomics and visualization which can facilitate precise and careful dissection in the Ladd's procedure. V478 Gastrointestinal Stromal Tumor: Robotic Transanal Minimally Invasive Surgical Excision Michael E Dolberg, MD; Natalie Ceballos, MD; Memorial Healthcare System This video presents a case of a 44-year-old male with a history of diverticulitis who underwent a colonoscopy which revealed a submucosal mass in the distal rectum. A digital rectal exam revealed a large, fixed mass in the right posterior lateral position approximately 6 cm from the anal verge. The patient underwent a robotic transanal excision of the rectal mass. He was discharged home from the recovery room and had an uneventful postoperative course. The final pathology revealed a gastrointestinal stromal tumor. This case highlights the advantages of a robotic transanal minimally invasive surgical technique. V479 Laparoscopic Sleeve Gastrectomy in a Patient with Situs Inversus Totalis Carlos Delgado, MD; Advent Health Orlando As obesity and associated co-morbidities continue to plague Americans, bariatric surgery has become a safe and reliable ameliorative method. Increasing patient numbers has also increased the incidence of patients with unusual anatomy such as situs inversus. Surgeons' laparoscopic abilities have also increased exponentially, thus reducing surgical contraindications for such patients, despite the special challenge of operating mirror fashion. The literature suggests various burden-lessening patient positions and techniques; all emphasize proper preoperative workup and planning. This video of a female with situs inversus undergoing a sleeve gastrectomy presents the usual instrument configuration but in the mirror fashion and her postoperative course. V480 Chronic Inguinal Pain: Robotic-assisted Mesh Removal After Laparoscopic Right Inguinal Hernia Repair Julia Button, MD; Amy Holstrom, MD; Gregory Dakin, MD, FACS, FASMBS; Cheguevara Afaneh, MD, FACS, FASMBS; Omar Bellorin-Marin, MD, FACS, FASMBS; New York Presbyterian-Weill Cornell 60-year-old man presented for evaluation of a recurrent inguinal hernia. He underwent an open right IHR with subsequent recurrence, followed by a robotic recurrent right IHR with mesh. Since that operation, he noted chronic right groin pain and higher right sided testicle. Pain was exacerbated with activity and impaired his quality of life. Pre-operative imaging demonstrated no hernia recurrence and normal testicular blood flow. He underwent robotic exploration with mesh explant. Mesh was found densely adherent to inguinal ring and spermatic cord. It was removed with absorbable mesh placement. Patient was discharged on post-operative day 1 with improvement in pain. V481 State of the Art Performance of a Procedure—Robotic Splenic Flexure Mobilization Vincent L Brown, MD; Henry Lujan, MD, FACS, FASCRS; Jackson South Medical Center Over the years, there have been many publications and video presentations aiding in the standardization for minimally invasive splenic flexure mobilization. We understand the importance of acquiring this technique, because a tension free anastomosis subsequently leads to a lower rate of anastomotic failures. In this " State of the Art Performance of a Procedure" video, I present technical aspects for robotic splenic flexure mobilization, discuss limitations while using the robotic platform, and review the three approaches for splenic flexure mobilization; the lateral, anterior, and inferiomedial approaches. V482 Laparoscopic Repair of an Acute Incarcerated Post-esophagectomy Para-Conduit Hernia Giulia S Rizzo, MD; Nicole Cherng, MD; John J Kelly, MD; UMass Memorial Health Our video demonstrates a laparoscopic repair of a symptomatic acute incarcerated Type IV para-conduit hiatal hernia with mesh in a patient who underwent an Ivor Lewis esophagectomy for esophageal cancer 4 years prior. We performed a laparoscopic repair by reducing the hernia contents, partially closing the hernia defect, and reinforcing with mesh. Additionally, we performed a pexy of the transverse colon to the anterior abdominal wall and diaphragm to prevent future herniation. His post-operative course was overall uncomplicated. Approximately 16 months post-op, CT images show no recurrence of his hiatal hernia and he remains asymptomatic. V483 Recurrent Hiatal Hernia 5 years After BioA Benjamin Clapp, MD 1; Andres Vivar2; 1Texas Tech HSC Paul Foster School of Medicine; 2Universidad Autonoma de Guadalajara This video is a case report of a patient who underwent a hiatal hernia repair with Bio A five years prior. She presented with a recurrence. Highlights of the video include the appearance of the recurrence at 5 years after placement of a bioabsorbable mesh. Also the technique of approaching a recurrent hiatal hernia is demonstrated. A literature review of the use of mesh is also presented. V484 Hepatic Cyst Fenestration to Facilitate Laparoscopic Cholecystectomy Tiffany C Lee, MD, MS; R. Cutler Quillin IV, MD; Jennifer Colvin, MD; University of Cincinnati 50 year old woman with history of gastroesophageal reflux disease s/p Dor fundoplication and morbid obesity s/p single anastomosis duodenoileostomy, who presented with symptomatic cholelithiasis. Additionally, she was noted on CT and MRCP to have numerous simple hepatic cysts, including two large cysts adjacent to the gallbladder, potentially causing some mass effect. Therefore, she underwent laparoscopic hepatic cyst fenestration to facilitate cholecystectomy and intraoperative cholangiogram. V485 Video Case Report: Ectopic Pancreas Resection With Concomitant Sleeve Gastrectomy For Morbid Obesity Aly Elbahrawy, MD, FACS; Talat Albeiti, MD; Samah Melebari, MD; King Abdullah Medical City Ectopic pancreatic tissue is a rare entity. We report a 19-year-old male with a BMI 49.8 kg/m2, presented to bariatric surgery clinic. Pre-operative EGD revealed 3 cm submucosal mass in gastric body. Biopsy was inconclusive. After counselling, sleeve gastrectomy, with mass free-margin resection was performed, intra-operative EGD confirmed the complete excision. Histopathology revealed 2.5X2.2 cm ectopic pancreatic tissue with 1 cm free margin. To the best of our knowledge there are very few cases of ectopic pancreas reported in relation to bariatric surgery. In our case we demonstrated that concomitant bariatric surgery with excision of the heterotrophic pancreatic tissue did not add any morbidity. V487 Extended Totally Extraperitoneal Repair of Ventral Hernia and Diastasis Recti from Low Pelvic Port Sites Devi Bavishi; Thomas W Clements; Jonah Stulberg; University of Texas Houston Retrorectus mesh placement and closure of the midline provide excellent long-term results for patients undergoing ventral hernia and rectus diastasis repairs. Wide mesh reinforcement of the midline from xiphoid to pubis with minimal physiologic stress makes eTEP an outpatient procedure for most patients. All these factors decrease pain, infection and recurrence. We show a novel port site placement for eTEP repairs in the pelvis. Supra-pubic ports allow for a cosmetic result by "hiding" the incisions low in the pelvis and at the same time also allows good visualization. V488 Robotic Roux-en-Y Hepaticojejunostomy for Type E4 Vasculo-Biliary Injury Atli S Valgardsson, MD; Edwin O Onkendi, MD, MBChB; Texas Tech University Health and Science Center This video demonstrates biliary reconstruction after a complex bile duct injury during laparoscopic cholecystectomy. The patient had been discharged but returned with bile peritonitis. The injuries identified were ligation and division of the right hepatic artery, avulsion of the confluence of the right and left hepatic ducts injuring the left hepatic, right anterior and right posterior hepatic ducts and ligation and division of the common bile duct consistent with type E4 Bismuth-Strasberg classification. He underwent a robotic Roux-en-Y hepaticojejunostomy were the left and right anterior hepatic ducts were joined in one hepaticojejunostomy and the right posterior in a separate hepaticojejunostomy. V489 Young at Heart: An Adult Case of Idiopathic Colo-Colonic Intussusception Francisco Quinteros, MD1; Paige Blinn, MD 2; Vadim Lyukesemburg, MD3; Rami Lufti, MD4; Lindsey Klingbeil, MD1; Andres Giovannetti, MD1; John Mitko, MD1; 1Clinical Assissant Professor of Chicago Medical School; 2University of Illinois at Chicago; 3Advocate Illinois Masonic Medical Center; 4Clinical Professor of Chicago Medical School Intussusception is a rare cause of intestinal obstruction in adults. While the vast majority of intussusception cases in children are idiopathic, the opposite is true in adults where the majority are attributable to a pathologic lead point. We present a case of an adult female with abdominal pain and bloody diarrhea ultimately found to have a colo-colonic intussusception. The patient subsequently underwent a laparoscopic right hemicolectomy after she was resuscitated. Pathology was remarkable only for ischemic and edematous colonic tissue. Here we not only present a case of adult colo-colonic intussusception but also one that is idiopathic. V490 Robotic eTEP, TAR for Incisional Right Flank Hernia Repair Emanuel Mejias Lafontaine, MD; Masoud S Chopan, DO; Rockson Liu, MD, FACS; Alta Bates Summit Medical Center This video will present a Robotic Etep–TAR approach for an incisional right flank hernia repair with special emphasis on: (1) patient positioning (2) TAR technique and (3) closure of a large defect utilizing our progressive tensioning technique. The eTEP-TAR approach was chosen to allow easier port placement and robot docking. Furthermore, it provided extensive mesh overlap in the retromuscular space. Finally, this approach minimized the need for extensive lysis of adhesions. This video further details the ability of progressive tensioning to close large defects that would otherwise have been difficult to close with traditional techniques. V491 Laparo-endoscopic Enterotomy for Removal of Impacted Esophagojejunostomy Stent Francisco Ferri, MD; Ana Pena, MD; Francesco De Salvio, MD; Raul J. Rosenthal, MD; Cleveland Clinic Florida The patient is 61 years old female with a past surgical history of sleeve gastrectomy in 2018 complicated by a leak at the esophageal-gastric junction that was addressed with stent placement. A second stent was then placed to free up the original stent. Our team performed a laparoscopic enterotomy to remove both stents. The incision was made distally to the stent. The most recent stent was removed easily. The proximal section of the old stent required extensive tissue degranulation with the aid of an endoscopic view. The proximal suture was visualized, and the stent was removed with an inversion technique. V492 Robotic Approach for Right Posterior Hepatic Tumors: Reaching Hard-To-Reach Places Sarah Lund, MD; Sean Cleary, MD; Patrick Starlinger, MD, PhD; Susanne G Warner, MD; Mayo Clinic Laparoscopic resection of right posterior hepatic tumors is challenging. When performed open, these cases are considered "incision dominant" because their primary morbidity stems from that of the incision. We present a robotic approach for non-anatomic partial resections of hard-to-reach right posterior hepatic tumors. We illustrate steps for safe resection and demonstrate useful techniques for mobilization and hemostasis. In our experience, a robotic approach to right posterior lesions improves visualization and instrument maneuverability while enabling a minimally invasive approach. V493 Refractory GERD After Sleeve Gastrectomy Managed by Hiatal Hernia Repair with and without Mesh Reinforcement Abby C Larson, MD 1; David Spector, MD2; 1Brigham and Women's Hospital; 2Brigham and Women's Faulkner Hospital A 64-year-old male 11 years after a sleeve gastrectomy underwent hiatal hernia repair without mesh reinforcement as management of refractory GERD. On postoperative day one, imagining demonstrated recurrence; the patient was immediately taken to surgery. The recurrent hiatal hernia was reduced. The crura were further approximated with sutures, and then reinforced with biologic mesh and biologic glue. The patient was discharged and is now off PPI's with complete resolution of reflux symptoms. This case demonstrates the potential benefit of mesh reinforcement in this setting. Our unique technique for mesh reinforcement helps anchor the esophagogastric junction obviating the need for gastropexy. V494 Robotic Hiatal Hernia Repair with Stapled Conversion from Nissen to Toupet Fundoplication Bilal Koussayer, BS 1; Hannah Zuercher, BS1; Adham Saad, MD, FACS2; Joseph Sujka, MD2; 1USF Health Morsani College of Medicine; 2Bariatric & Foregut Surgery, Department of Surgery, University of South Florida The laparoscopic fundoplication is standard practice for treating patients with refractory gastroesophageal reflux disease (GERD). The Laparoscopic Nissen Fundoplication (LNF) technique is more often used to treat GERD rather than Laparoscopic Toupet Fundoplication (LTF). However, reoperation are higher in LNF populations occurring in up to 20% of cases, while LTF has about a 15% reoperation rate. Both have been equivalent in controlling GERD and currently there is no strong evidence that either method is more superior. Here we present a case of a 28-year-old male who underwent robotic hiatal hernia repair with stapled conversion from Nissen to Toupet fundoplication. V495 Laparoscopic Management of Closed Loop Small Bowel Obstruction After Esophagectomy Taylor Loui, Resident; Indraneil Mukherjee; SIUH 65 M with PMH of stage IIB adenocarcinoma of the gastroesophageal junction s/p neoadjuvant chemoradiation and ivor lewis esophagectomy with placement of a Witzel jejunostomy tube presented to the ED with abdominal pain and nausea. On exam he was peritonitic, and CT showed multiple loops of distended small bowel with interloop free fluid. He was taken to the OR emergently where we found a closed loop small bowel obstruction with transition point around the previous Witzel jejunostomy tube. We performed lysis of adhesions and post-operatively he was able to tolerate diet. V496 A Novel Surgical Approach to Splenectomy as Management for a Wandering Spleen Tashara Jones, MD; Thea Murray, MD; Christian DiLiberto, DO; Bakhtawar Mushtaq, MD; Robert Josloff, MD, FACS; Jefferson Abington Hospital This is a video of a robot-assisted laparoscopic splenectomy for a wandering spleen in a 59 year-old female who presented with worsening acute on chronic abdominal pain. Wandering spleen is a rare clinical condition characterized by laxity of the splenic ligaments causing hypermobility that can result in torsion of the splenic vasculature. Intra-operatively this patient's spleen was identified in the left hemi-abdomen without intact ligaments. Congested splenic vessels were located lateral to the splenic hilum indicative of volvulus. The splenic vasculature was divided via stapler and the spleen was removed. The patient did well post-operatively and was discharged home. V497 Laparoscopic TAPP Repair of Amyand Hernia and Appendectomy Amanda L Bader, MD; Aditya Jog; Jenny Shao, MD; University of Pennsylvania This is a 52-year-old male who presented with an Amyand hernia and underwent laparoscopic appendectomy and transabdominal preperitoneal repair of a right inguinal hernia. He presented with 4 days of right sided groin pain. On exam, he had an incarcerated right inguinal hernia. CT scan showed the appendix was contained within the hernia. He was taken to the operating room where first, the appendix was reduced and an appendectomy was completed. Then, a mesh based TAPP hernia repair was performed on the right side. There were no intraoperative complications. He had no issues or recurrence on follow up. V498 Provocative Leak Test Complication in Gastric Bypass, with Additional complications Benjamin Clapp, MD 1; Andres Vivar, BS2; Omar Ghanem, MD3; 1Texas Tech HSC Paul Foster School of Medicine; 2Universidad Autonoma de Guadalajara; 3Mayo Clinic, Rochester This video highlights a couple of complications during a laparoscopic Roux-en-Y gastric bypass. It includes three operations. The first complication is caused by an intraoperative leak test. The second operation has to do with bleeding and obstruction at the jejejejunostomy. The video shows all three surgeries with the CT scans. Technical aspects of revising a jejujejunostomy are shown and discussed. V500 Cholecystomegaly Treated with Laparoscopic Subtotal Fenestrated Cholecystectomy Kameko M Karasaki, MD, MS; Jessica Kieu, MD; Riley K Kitamura, MD, FACS; University of Hawaii This is a 73 year-old female who presented with one week of right upper quadrant pain. Her work-up revealed a severely inflamed and distended gallbladder displacing the duodenum, portal structures, and IVC. A percutaneous cholecystostomy tube was placed, and an interval laparoscopic cholecystectomy was attempted, however the gallbladder infundibulum was densely adherent to the duodenum and portal structures. A laparoscopic fenestrated subtotal cholecystectomy was performed with drainage of the gallbladder bed. Cholecystitis with massive distention of the gallbladder, or "cholecystomegaly", is an uncommon entity. We present a case of cholecystomegaly managed with percutaneous cholecystostomy tube and interval laparoscopic fenestrated cholecystectomy. V501 Laparoscopic Reduction of Recurrent Internal Hernia and Mesh Repair of Mesenteric Defect John W Keyloun, MD 1; Brian Cohen, MD1; Timothy R Shope, MD, FACS, FASMBS2; 1Medstar Georgetown University Hospital; 2Upstate Medical University Internal hernias after Roux-en-Y gastric bypass are a well-described complication often necessitating operative intervention. In this video, we describe a patient who presents with an internal hernia, after having suffered from three prior instances of internal herniation through the same mesenteric defect created by a previous bypass surgery. We describe a unique approach to repair, involving laparoscopic hernia reduction, repair of the mesenteric defect, and placement of a bioabsorbable mesh to reinforce the mesenteric defect repair. Reinforcement with bioabsorbable mesh has potential as a novel strategy and effective tool in patients with complex, recurrent herniation through mesenteric defects. V502 Laparoscopic Magnetic Duodeno-Ileostomy Michel Gagner, MD, FRCSC, FACS; Lamees Almutlaq, MD, FRSCSC; Westmount Square Surgical Center A side-to-side duodeno-ileostomy is accomplished using linear magnets delivered both by flexible endoscopy, while laparoscopic assistance provide adequate ileum measurements. A 43 y.o. male with previous sleeve gastrectomy, (BMI of 75.3 kg/m2), had hypertension, sleep apnea, Pre-diabetes, dyslipidemia, and bilateral lower limbs lymphedema. Three years later, he is having a second stage procedure (BMI of 42.5 kg/m2). The delayed compression anastomosis may decrease risk of bleeding and leaks, as after 4 weeks magnets pass. It is reversible, allow partial passage in the natural duodenum for possible ERCP if needed, and absorption of minerals and vitamins. V503 Robotic GIST Resection After Sleeve Gastrectomy Jordan R Purewal, MD; Seth Kipnis, MD, FACS, FASMBS; Jersey Shore University Medical Center We performed a robotic GIST resection for a patient that had previously undergone a laparoscopic sleeve gastrectomy 6 months prior. In this abstract we discuss the incidence of GIST in this patient population as well as the focus of literature currently. We show that robotic assisted surgery is a safe and adaptable technique for performing this procedure. V505 Robotic Extended Totally Extra-Peritoneal Repair (eTEP) of Combined Ventral and Inguinal Hernia David A Leenen, MD1; Marcoandrea Giorgi, MD1; Andrew Luhrs, MD 2; 1Brown University/Miriam Hospital; 2Brown University We present the case of a Robotic Extended Totally Extra-Peritoneal Repair of Combined Ventral and Inguinal Hernia. Using the robotic platform, we are able to avoid a hostile abdomen and complete both a ventral and inguinal hernia repair in a minimally invasive fashion. The retro-rectus space being continuous between the abdominal wall and pelvis facilitates this combination repair. V506 Laparoscopic Revision of Jejunojejunostomy with Lengthening of a Roux Limb for Bile Reflux Gastritis David A Leenen, MD; Melissa L Desouza, MD; Daniel Davila Bradley, MD; Christy M Dunst, MD, FACS; Kevin M Reavis, MD, FACS; Providence Portland Medical Center We present a laparoscopic revision of a jejunojejunostomy with lengthening of a roux limb for bile reflux gastritis. This technique, which can be used for any roux-en-y reconstruction anatomy, is a simple and relatively straight forward procedure to length the roux limb. Our technique involves resection of the prior jejunostomy, re-establishing continuity of the roux limb and common channels and then inserting the biliopancreatic limb at a more distal location. V507 The Appearing Cecal Bascule Vadim Lyuksemburg, MD1; Hani Ghandour, MD 2; Paige Blinn, MD2; Rami Lutfi, MD1; Francisco Quinteros, MD1; 1Chicago Institute of Advanced Surgery; 2University of Illinois This video demonstrates a laparoscopic right hemicolectomy in a 48-year-old female with chronic intermittent abdominal pain. She presented with worsening abdominal pain and initial CT scan was unremarkable; however, a repeat CT scan 2 h later demonstrated an acute finding of a cecal bascule with cecal distention. The patient was taken to the operating room and underwent a standard medical to lateral mobilization of the right colon with intracorporeal anastomosis performed in an isoperistaltic fashion. The patient tolerated the operation well with an uneventful postoperative course and she was discharged on POD2 tolerating a general diet. V508 Laparoscopic Removal of LINX Device and Toupet Fundoplication Ronald Orozco, MD; Hamza Hanif, MD; Seyed A Arshad, MD, MS; Edward Auyang, MD, MS, FACS; University of New Mexico School of Medicine We present a case of a patient status post magnetic sphincter augmentation with LINX device for chronic gastroesophageal reflux disease which was complicated by solid food dysphagia. The use of magnetic Sphincter Augmentation is becoming a more common treatment for gastroesophageal reflux. This complication was managed through laparoscopic LINX device removal and fundoplication creation. V509 Laparoscopic Management of Small Bowel Obstruction with Chylous Ascites Following Roux-en-Y Gastric Bypass Berna F Buyukozturk, MD; Susan K Campbell, MD; Wasef Abu-Jaish, MD; University of Vermont Medical Center A 34-year-old female with a history of LRYGB 5 years ago, and prior repair of an internal hernia, presented with small bowel obstruction concerning for an internal hernia at Peterson's defect. Our video shows an exploratory laparoscopy with findings of chylous ascites and a constrictive adhesive band where small bowel was trapped. The band was divided, and the space between Roux limb and gastric remnant was closed. Chyloperitoneum due to small bowel obstruction is rare, but can occur due to internal hernia following gastric bypass. Our case illustrates the possibility of disruption in lymphatics as a result of internal hernia. V510 Robotic Parastomal Hernia Repair with Posterior Component Separation Sonam G Kapadia, MD; Mohammad S Sultany, MD; Shushmita M Ahmed, MD; Hazem Shamseddeen, MD; UC Davis Medical Center Our case demonstrates a robotic parastomal hernia repair with posterior component separation in a 74-year-old overweight (BMI 29) female patient with a prior history of rectal cancer status post abdominal perineal resection (APR) five years preoperatively presenting with a symptomatic midline incisional and left lower quadrant parastomal hernia. Our approach was a transabdominal preperitoneal (TAPP) repair in right abdomen and unilateral transversus abdominis release (TAR) with retro-rectus repair with heavy polypropylene mesh using a modified Sugarbaker technique in the peristomal/left abdomen. Of note, an incidental left indirect inguinal hernia was found and also simultaneously repaired. V511 Situs Inversus Gallbladder and Management of Bile Leak with Use of ICG Megan Shepherd; Melissa Phillips, MD; University of Tennessee at Knoxville Our video presentation is of a robotic assisted cholecystectomy with use of firefly and indocyanine green (ICG). Since this patient has situs inversus the left hand was the working arm, and the right hand was used as the retracting arm. Upon inspection there is noted to be a small bile leak that likely would have been missed if not for the use of the ICG and firefly technology. The leaks are located and clipped with the assistance of the ICG and the robot. V512 Rectal Perforation with Primary Repair via Transanal Minimally Invasive Surgery (TAMIS) Rachel Pruett, MD; Michael Dolberg, MD, FACS, FASCRS; Memorial Healthcare System Patient is an 89 yr female with recent history of rectal bleeding who presented with abdominal pain after undergoing a barium enema at an outside facility. CT revealed a large amount of extra-luminal contrast in the pelvis and flexible sigmoidoscopy confirmed a full-thickness rectal perforation approximately 7 cm from the anal verge. Repair was completed via TAMIS. At the end of the procedure, the wound was completely closed with no observable narrowing of the lumen of the bowel. Therefore, in select patients, TAMIS is a viable method of surgical repair for rectal perforations and should be considered when managing traumatic injuries. V513 Laparoscopic Cholecystectomy with CBD Exploration with Removal of Impacted CBD Stones Using Fogarty Catheter in Case of Multiple Failed ERCP Gyan Saurabh; Rahil Kumar; Lady Hardinge Medical College A 35 year old lady presented to surgery opd with complains of pain in the right upper quadrant, vomiting and yellowish discoloration of eyes and skin with no history of any prodromal symptoms and no history of fever. On examination patient was icteric with rest of systemic examination found to be normal. A USG and MRCP was conducted which was suggestive of choledocholithiasis and patient underwent ERCP with stenting, however ever after papillotomy, ballon trolling and CBD stenting, a repeat MRCP showed multiple CBD stones and hence she was planned for laparoscopic CBD exploration. V514 Emergency Laparoscopic Repair of an Incarcerated Amyand Hernia Yun Le Linn, BA, MBBS, MRCSEd; Yuen Soon; Man Hon Tang; Ng Teng Fong General Hospital We present a rare case of a patient with incarcerated Amyand hernia which was reduced laparoscopically and repaired via the transabdominal pre-peritoneal approach (TAPP). Our patient was a 57-year-old male who presented with six-days duration of irreducible right inguinoscrotal hernia. Diagnostic laparoscopy demonstrated minimal free fluid and healthy bowels. A Type 1 Amyand hernia was noted. This was reduced under laparoscopy and TAPP repair was performed. He was discharged the following day. In type 2 or 3 incarcerated Amyand hernias, a safer approach would be to performed an appendicectomy first and delaying definitive hernia mesh repair to a later date. V515 Hole-y S***! Repair of Iatrogenic Gastrojejunal Anastomosis Perforation Mimi Tan, MD 1; Valerie J Halpin, MD1; Kevin M Reavis, MD2; 1Legacy Good Samaritan; 2The Oregon Clinic This is a case of a 61 year-old female who underwent sleeve gastrectomy for morbid obesity that was complicated by refractory reflux disease for which she underwent laparoscopic conversion to gastric bypass with hiatal hernia repair and bilateral truncal vagotomy. Intraoperatively, an iatrogenic anastomotic perforation was noted during creation of the gastrojejunostomy which was managed with primary repair. This case reviews intraoperative decision making in addressing this complication. V516 Recurrent Cerebrospinal Fluid Pseudocyst (CSFoma) Following VP Shunt Placement for NPH David Roberts; Thomas Kania, MD; Olivia Haney, MD; Indraneil Mukherjee, MD, MBBS; Staten Island University Hospital A 70-year-old female s/p VP shunt placement for NPH presented to the ED for abdominal discomfort. CT showed coiling of the catheter and a large CSF collection inside the abdominal wall. The collection was drained robotically, and the catheter was reduced back into the peritoneal cavity. 1 month following revision the patient presented to the clinic with recurrent symptoms of NPH. CT showed recurrent coiling of the catheter and CSF fluid collection in the RUQ. The collection was drained, and the catheter was rerouted subcutaneously from the RUQ to the LUQ. The patient was discharged home the same day. V517 Laparoscopic Common Bile Duct Exploration: A Procedure for the General Surgeon's Armamentarium Chau M Hoang 1; H. Hande Aydinli, MD2; George Ferzli, MD3; 1NYC Health + Hospitals/Kings County; 2NYU Langone/Brooklyn; 3NYU Langone The patient had a prior surgical history of sleeve gastrectomy followed by conversion to Roux-en-Y gastric bypass, ventral hernia repair with mesh, and exploratory laparotomy and small bowel resection for incarceration. She presented with choledocholithiasis. We started with lysis of adhesions and cholecystectomy, then turned to exploring the common bile duct. A vertical incision was made with a scalpel, with immediate expulsion of sludge and debris. The duct was irrigated with suction irrigator, followed by red rubber catheter, and then by Fogarty catheter. A modified T-tube was placed into the duct, and the choledochotomy was closed with absorbable suture. V518 Combined SILS/Robotic Approach for Simultaneous Transverse Loop Colostomy Reversal and Colorectal Anastomosis Tarek Hassab, MD 1; Matthew Zeller, DO1; Atiyah Tidd-Johnson2; Joshua Wolf, MD1; 1Sinai Hospital of Baltimore; 2American University of Antigua Our case explores the operative care of a 61-year-old male with an uncommon anatomical presentation resulting from a prior loop transverse colostomy and sigmoidectomy for acute diverticular disease. We illustrate our single-stage approach by utilizing a GelPOINT® mini at the prior ostomy site to allow single incision laparoscopic surgery (SILS), robotic surgery, extracorporeal anastomosis, and removal of specimens. V519 A Case of Perforation After One Anastomosis Gastric Bypass Jonathan Jenkins; Zhamak Khorgami, MD; Robert Lim, MD; Geoffrey Chow, MD; University of Oklahoma—Tulsa Here we demonstrate laparoscopic management of a perforated marginal ulcer after a one-anastomosis-gastric-bypass. The patient underwent OAGB in Mexico 29 days before presenting with abdominal pain and tachycardia. In the operating room a 2.5cmX1.5 cm defect immediate to the anastomosis was repaired. Literature estimates ulceration in 0.5% of cases, though acutal rates of perforation may have significant variability. V520 Robotic Assisted Surgery for Giant Esophageal Epiphrenic Diverticulum Najiha Farooqi; Felipe Pacheco; Olivia Lossia; Samuel Shaheen; Maher Ghanem; Central Michigan University Introduction: 68-year-old female presented with a large symptomatic epiphrenic esophageal diverticulum. She underwent a laparoscopic robotic-assisted diverticulectomy with myotomy. Methods and Procedures: A robotic-assisted approach using the DaVinci Xi was used. A 7.5 cm chronic epiphrenic diverticulum was found. Stapled diverticulectomy with a longitudinal myotomy on the opposite side was performed. Conclusion: Patient tolerated the surgery without significant complications. She was discharged home on post-operative day 5. Large esophageal epiphrenic diverticuli with significant adhesions to mediastinal structures can be removed safely and efficiently robotically through an abdominal approach only. V522 Removal Perfix Plug Mes Dham Mobarak, Mr; Sandwell and West Birmingham Hospitals this video on TEP and how tok, ighate sac with endo-loop andremover previous mesh, it is difficukt to renove old mesh V523 Intestinal Perforation in a Patient with a History of Laparoscopic Whipple Fresia Cicibel Casas Bueno, Doctor1; Harold André Patrick Guerrero Martínez, Doctor1; Felix Camacho Zacarías, General Surgeon 2; Manuel Moreno Gonzales, General Surgeon3; Luis Poggi Machuca, Abdominal Oncology Surgery4; 1Cayetano Heredia University; 2Cayetano Heredia Hospital; 3Mayo Clinic; 4Edgardo Rebagliati Martins Hospital Case of a 81 year-old male patient with a history of laparoscopic whipple procedure performed 6 years ago with one day of abdominal distension and pain. CT scan evidenced pneumoperitoneum and aerobilia. During laparoscopy, multiple distended intestinal bowel loops, purulent material, multiple diverticula and adhesions were found. Pneumatic test was performed and was negative. In order to look for leaks, we decided to inject methylene blue. We noticed a small leak in the posterior wall of the gastrointestinal anastomosis, it was sutured. The impermeability was verified with a negative methylene blue test. Finally, an abdominal washout was performed. V524 An Innovative Technique for Extracorporeal Knotting in Endoscopy Narendra V Lohokare, MD, DNB, FACS; Aditi N Lohokare, MBA; Siddhakala Hospital Aims and Objective: To introduce extracorporeal knotting using Maryland grasper. Methods: Maryland grasper is used for stump tying instead of Knot pusher. After the Roeder's knot is prepared it's held and introduced through the port. Once the loop position is fixed it's tightened by pushing with Maryland grasper. Results: Maryland grasper helps to reposition the knot and handle stump easily without changing of instrument. This reduces need to have an extra instrument which has only one use, saving on expenditures. Conclusion: Maryland grasper is as convenient as knot pusher for extracorporeal knotting with more comfort to use. V525 Robotic-assisted Distalization of Roux-en-Y Gastric Bypass Michel Cordies Perez, MD; Rocio Castillo Larios, MD; Lorna Evans, MD; Alvaro Ducas, MD; Fernando Elli, MD, FACS; Mayo Clinic. Jacksonville Florida Robotic-assisted revision of RYGB with limb distalization is a safe and feasible option for patients with inadequate weight loss or weight regain. In this patient distalization was used like first step, this procedure helps through the weight loss to repair complications like hiatal hernia or resizing gastric pouch in a second time surgery. However, it is important to have on mind to create a Common Channel long enough (> 150 cm) to avoid others serious complications like persistent vitamin deficiencies, protein malnutrition, debilitating defecation patterns, and reoperations in some patients. Keywords: Roux en Y Gastric Bypass. Hiatal hernia. Distalization. V526 Novel Technique for Maintaining Wrap Orientation During Nissen Fundoplication Amelie Lueders, MD; Singh Kirpal, MD; Ascension St Vincent Indianapolis Gastroesophageal reflux is one of the most common diseases of the western world and results in significant burden on the health care system. Nissen fundoplication has been established since the 1950s as an efficient method of treatment. Several research papers have addressed complications of Nissen fundoplication including gas bloat syndrome, wrap failure, slippage and dysphagia. Comparison of outcomes is impacted by significant differences in technique between surgeons. Here we present a novel approach to maintaining wrap orientation with the use of 2 marking sutures. Correct orientation and use of proper fundus may reduce incidence of postoperative complications. V527 Laparoscopic Repair with Mesh of Right Diaphragm Eventration Konstantinos P Economopoulos, MD, PhD, MEng; Sabino Zani Jr, MD, FACS; Alisan Fathalizadeh, MD, MPH, FACS; Duke University Medical Center This is a case of a 35-year-old female with history of hypertension, drug-induced pancreatitis and a right-sided diaphragmatic hernia secondary to a motor vehicle collision. Extensive eventration of the right diaphragm containing right colon and right kidney was seen on imaging. Patient underwent a laparoscopic repair of the eventration of the right diaphragm after mobilization of the right liver. The diaphragmatic hole was suture-closed and was reinforced with a permanent mesh. Gerota's fascia was pexied to the right lateral wall and the colon was returned to its normal anatomic position. Patient's symptoms are resolved postoperatively. V529 Concomitant Laparoscopic Robotic-Assisted? Morgagni and Hiatal Hernia Repair? Charles L Cole III, MD; Michael J Furey, DO; Alexandra M Falvo, MD; Ryan D Horsley, DO; Geisinger We present the case of a 69-year-old female with a history of morbid obesity, now status post Roux-en-Y gastric bypass, who presented to the emergency department at our institution with a 1-day history of sudden onset back pain and 2-day history of constipation. On imaging, she was found to have both a Morgagni diaphragmatic hernia and a hiatal hernia. She successfully underwent urgent concomitant laparoscopic robotic assisted Morgagni and hiatal hernia repair with mesh. She was discharged home on post-op day 2 with excellent post-operative progress and resolution of her preoperative symptoms. V531 Technical Approach for Diagnostic Laparoscopy in Patients with Suspected Peritoneal Carcinomatosis Felipe Lopez-Ramirez, MD; Vadim Gushchin, MD, FACS; Mary C King, BS; Armando Sardi, MD, FACS; Mercy Medical Center Surgical oncologists use diagnostic laparoscopy as a tool to evaluate peritoneal disease in patients with advanced malignancies. A technical approach to systematically evaluating the peritoneal cavity is provided in this video, along with examples of common findings. General surgeons will find this information useful for cases requiring initial disease staging and provides useful steps to take when incidental peritoneal carcinomatosis is encountered during routine non-oncological procedures. With the proper and thorough technique, including documentation of key regions and biopsies, diagnostic laparoscopy provides useful information that allows for better surgical planning and disease staging. V532 Laparoscopic Conversion of D-SLEEVE to Roux-en-Y Gastric Bypass after Early Hiatal Hernia Recurrence Ahmad Elnahas, MSc, MD; Ruxandra Bogdan; Christopher Schlachta, MD; Nawar AlKhamesi; Jeff Hawel; Western University A 50-year-old female presented with obstructive symptoms fifteen days postoperatively from a gastric sleeve and hiatal hernia repair performed out of country. Imaging demonstrated recurrence of the hiatal hernia. The patient was taken to the operating room for exploration and repair of her recurrent hiatal hernia. Intraoperatively, a D-sleeve modification was noted and the redundant fundus was resected. The stomach was returned to the abdominal cavity but residual corkscrewing of the sleeve caused concern for further obstruction. The sleeve was converted to a Roux-en-Ygastric bypass and the patient has transitioned to a bariatric diet with resolution of her obstructive symptoms. V533 Laparoscopic Enucleation of Esophageal Leiomyoma Chalerm Eurboonyanun, Assistant Professor; Kulyada Eurboonyanun; Wasin Chakuttrikul; Jakrapan Wittayapairoch, Assistant Professor; Somchai Ruangwannasak, Assistant Professor; Srinagarind Hospital, Khon Kaen University A 61-year-old man arrived at the hospital with clinical hematemesis. Esophagogastroduodenoscopy showed antral atrophic gastritis and submucosal tumor of the distal esophagus. He was diagnosed with a benign tumor originating from the muscular layer of the esophagus by endoscopic ultrasonography. The tumor was removed entirely by the laparoscopic enucleation technique. The patient was allowed to start his meal on the next day of the operation and could be discharged within 48 h after the procedure. In summary, laparoscopic enucleation can be performed effectively and safely for leiomyomas of the esophagogastric junction in centers experienced with minimally invasive surgery. V534 Paraesophageal Hernia—The Gastrojejunostomy From a Prior Laparoscopic Roux-en-Y Gastric Bypass and Hiatal Hernia Repair is in the Chest: What To Do? Chau M Hoang 1; Juan C Garces, MD2; George Ferzli, MD, FACS3; 1NYC Health + Hospitals/Kings County; 2NYC Health + Hospitals/Jacobi Medical Center; 3NYU Langone Four years after laparoscopic Roux-en-Y gastric bypass and hiatal hernia repair, the patient redeveloped a large paraesophageal hernia. Intra-op, the gastrojejunostomy was in the thorax. Adhesions under the liver were dissected. The left lobe of the liver was mobilized and retracted medially with a locking grasper on the right crus. We took down the adhesions to the remnant stomach, dissected along the left and right crura. Dissection was carried to the mediastinum and the esophagus was circumferentially freed. Crura were reapproximated. The remnant stomach was used for fundoplication, with additional anchoring to the crura. No mesh was needed. V535 Robotic Excision of Infected Ventral Hernia Mesh Indraneil Mukherjee 1; Harpreet Kaur2; Adeel Shamim3; Nisha Narula1; Lisa Shimotake1; Karen E Gibbs4; 1Staten Island University Hospital—Northwell Health; 2Bronx Care Hospital System; 3Mercy Hospital, Fort Smith; 4Yale University—Bridgeport A 50 year old gentlemen with a previous history significant for bariatric surgery, Crohn's Disease and Diabetes, presented to our hospital with multiple episodes of intermittent abdominal pain over the last two years. He had a ventral hernia repair with mesh 2 years ago. Since then he had a draining sinus and had needed multiple incision and Drainages as well as multiple courses of antibiotics. He was taken to the operating room for Robotic resection of meshoma and closure of the sinus tract. Since then he is doing well with no further drainage, hernia, or any other symptoms. V536 Colostomy Takedown with Intra-Stomal EEA Anastomosis Ilan Layman, MS, MD; Andrew Luhrs, MD; Brown University This is a case of a Forty-Seven year old female who initially presented with acute complicated diverticulitis requiring an emergent Hartman's procedure. She has a history of stroke, hyperlipidemia, and hypothyroidism, with no prior colonoscopies and a history of cesarean section. The patient presented six months later for an elective parastomal hernia repair and colostomy reversal through a robotic approach. The colostomy takedown was completed with an end-to-end anastomosis of the colon through the stoma. V538 Laparoscopic Cholecystectomy with Intraoperative Cholangiography and Laparoscopic Common Bile Duct Exploration via Choledochoscopy Eleanor R Johnson, MD, MPH; Megan E Campany; Marko A Laitinen, MD; Britton B Donato, MD, MPH, MS; Irving A Jorge, MD, MBA, FACS; Mayo Clinic Arizona Laparoscopic cholecystectomy is a one of the most performed procedures in the United States. Laparoscopic cholecystectomy dissection is well defined; however, there are several methods for clearing the common bile duct of stones if clearance is indicated. The methods include endoscopic retrograde cholangiopancreatography (ERCP), transcystic exploration under fluoroscopic guidance, and common bile duct exploration via choledochoscopy. Demonstrated here is an example of laparoscopic cholecystectomy with intraoperative cholangiography and laparoscopic common bile duct exploration via choledochoscopy. This case demonstrates the effectiveness of c choledochoscopy for management choledocholithiasis, allowing the patient to undergo a single procedure and avoid ERCP. V539 Migration of Intra-Gastric Balloon Resulting in SBO Sherif Aly, MD; Eric Sheu, MD, PhD; Brigham & Women's Hospital We describe a case of a 38-year-old woman (BMI = 32.5 kg/m2) who presented to the emergency department with a small bowel obstruction from migration of an intragastric balloon. The patient underwent intragastric balloon placement approximately one year ago in Germany. She presented to the ED with one day of PO intolerance, nausea and vomiting. She underwent a CT of the A/P showing migration of the balloon into the mid jejunum resulting in a small bowel obstruction. Endoscopic retrieval was not an option given the distal location of the balloon, and she was taken the OR urgently for laparoscopic removal. V540 Robotic Assisted Laparoscopic Traumatic Abdominal Wall Hernia Repair Kylie Dickman, MD; Gregory Johnston, DO; Aaron Moore, MD; Sydni Imel, DO; Mercy St. Vincent Medical Center A 61-year-old male presented as a polytrauma to a Level 1 trauma center after a semi-truck loading dock incident. A 6 cm traumatic abdominal wall hernia (TAWH) was identified in the right upper quadrant containing a portion of the ascending colon. After initial stabilization, the patient was taken to the operating room for robotic-assisted laparoscopic primary repair of the TAWH. TAWHs are an uncommon occurrence secondary to blunt abdominal injury. We demonstrate a robotic-assisted laparoscopic repair as a safe and valid approach for the treatment of a TAWH. V541 Natural Orifice Specimen Extraction (NOSE) Technique of Low Anterior Resection with Single Staple Technique Raju KVVN; Pavan Kumar Jonnada; Zeeba Usofi; Syed N Nusrath; Madhu Narayana; Pradeep Keshri; BIACHRI This is a video demonstration of natural orifice specimen extraction after low anterior resection technique using single staple for the resection of supra anal tumours of the lower third of rectum. This novel technique aims to achieve scarless surgery minimising the operative morbidity and hospital stay. Hence, we describe about this procedure and describe in detail. V543 Laparoscopic Removal of Enterolith Causing Mechanical Small Bowel Obstruction: A Case Report Marissa Novack; Dylan Tanzer; Caitlin Galbo; Aaron Hoffman; University at Buffalo Enteroliths are an uncommon cause of small bowel obstruction and exceedingly rarer is the need for operative intervention for resolution of such obstructions. We present a case of a patient presenting with duodenal diverticulitis. Diagnostic EGD resulted in dislodgement of the enterolith previously contained in the diverticulum, leading to impaction and mechanical small bowel obstruction. Patient underwent laparoscopic removal of enterolith and primary repair of enterotomy. Previous published case reports for similar presentations describe open techniques, making this the first instance of intervention in a laparoscopic manner. V544 Migrated Gastrojejunal Stent With Laparoscopic Removal in a Bariatric Patient Elliot S Toy; Gustavo Bello, MD; AdventHealth Orlando This is a case of a 67 year old female who had a previous history of a gastric bypass with chronic gastrojejunal anastomotic stricturing. She underwent stenting at an outside hospital in which led to distal migration. Given failure to pass into the colon, this was retrieved laparoscopically. V545 Robotic eTEP Ventral Hernia and Bilateral Inguinal Hernia Repair Jenny Zhang; Andrew Luhrs; Warren Alpert Medical School of Brown University A 65-year-old male presented with a ventral hernia and bilateral inguinal hernias. We elected to perform a robotic eTEP repair for his three hernias. We initially docked the robot on the left side of the patient and developed the retrorectus plane. We reduced the hernia and dissected free the hernia sac. Then we re-docked the robot for a top down approach to address his bilateral inguinal hernias. We used Progrip mesh for his inguinal hernias and a light weight polypropylene mesh for his ventral hernia. The meshes sat in good position and the patient tolerated the procedure well. V546 Robotic Harvest of an Omental Free Flap for a Forearm Defect after MVC Robert J King, MD; Michelle Son, MD; Iman Ghaderi, MD, MSc, MHPE, FACS; Tolga Turker, MD; Banner University Medical Center This is a case report of a healthy 25-year-old man who was involved in a motor vehicle collision and suffered a crush injury to his right arm. He underwent multiple attempts at local tissue coverage which ultimately failed. Minimally invasive surgery was consulted for a free omental flap for a large area of soft tissue coverage. A successful robotic assisted harvest of an omental free flap was completed. The patient had a superior functional outcome, as the free flap provided a more suitable environment for tendon excursion in the forearm over skin grafting alone.